Physical therapy approaches are often advocated as the first treatment choices for reducing spasticity and are deemed as the foundation upon which other therapies are built (Merritt 1981; Kirshblum 1999; Rosche 2002). Despite these contentions, there is a relative paucity of literature addressing the efficacy of either the passive techniques noted in the previous section or approaches involving active movement in individuals with SCI. In practice, active movement approaches may be conducted using a variety of exercise forms that may also provide benefits beyond spasticity reduction (e.g., strength, endurance, gait re-training). The studies meeting the criteria for the present review involve exercises performed in a therapeutic pool (i.e., hydrotherapy) (Kesiktas et al. 2004) or those associated with functional electrical stimulation (FES)-assisted cycling (Krause et al. 2008) or locomotor training programs, whether assisted by FES (Granat et al. 1993; Mirbagheri et al. 2002) or a FES-powered orthosis (Thoumie et al. 1995).
All studies demonstrated positive benefits for at least one outcome measure associated with spasticity. However, it should be noted that results between two spasticity-related outcome measures within some studies were not always consistent although most investigators employed the Ashworth or modified Ashworth Scale to assess spasticity.
Krause et al. (2008) used a randomized, cross-over study design in which five complete ASIA A clients with SCI underwent 1) FES cycling and 2) passive movement by a motor-assisted cycling ergometer. For both of the interventions, the legs were moved for the same period of time at the same velocity and frequency. The study demonstrated that FES (i.e., active muscle contractions) was significantly more effective than passive movements at reducing spastic muscle tone in individuals with complete SCI, although even passive movement resulted in spasticity reductions. This was indicated by a greater reduction in the Modified Ashworth Scale for FES vs. passive movement (p<0.001 vs. p<0.05) respectively and also with the Pendulum Test (p=0.01). Further research may be useful in determining precise stimulation patterns to use for FES-cycling as Mela et al. (2001) have noted that specific stimulation frequency parameters may influence spastic reactions variably which suggests careful selection of stimulation parameters so as to optimize the delivery of FES as a clinical tool to reduce spasticity.
Kesiktas et al. (2004) employed an experimental non-RCT design to test the effectiveness of a water-based exercise (i.e., hydrotherapy) program in reducing spasticity in a group of individuals (n=10) with complete and incomplete paraplegia and tetraplegia. Subjects were matched within a treatment group (i.e., hydrotherapy + conventional rehabilitation) vs. a control group (conventional rehabilitation only) on the basis of age, gender, time post-injury, injury level and severity, spasticity (Ashworth) and function (FIM). This study produced consistent results across all spasticity-related measures with spasticity reductions evident following the 10 week hydrotherapy treatment program for both Ashworth Scale scores and the Penn Spasm Severity scores. The control group also showed significant spasticity reductions relative to baseline with these measures but not to the same degree. In addition to these measures, dosages of oral Baclofen were significantly reduced for those receiving hydrotherapy vs. conventional rehabilitation only (i.e., > 50%) and the hydrotherapy treated group made much greater FIM gains than did the control group. These latter results may reflect the deleterious effect that high Baclofen doses can have on motor and cognitive function and also the benefits of reduced spasticity on motor function. Kesiktas et al. (2004) did not mention how soon after the final intervention the measures were taken so there is no indication of how long the beneficial effect might be maintained.
The remaining studies using active movement-based approaches involved pre-post trial designs of FES-assisted walking with and without orthoses. Mishorbagheri et al. (2002) calculated reflex and intrinsic stiffness of the ankle by employing a mathematical model of position vs. torque resistance in response to perturbations as a means of assessing spasticity prior to and following a FES-assisted walking training program. This program involved 4 individuals with longstanding AIS C or D SCI who underwent locomotor training for a minimum of 16 months. Both reflex and intrinsic stiffness were reduced following training while another individual with SCI, but not actively involved in FES-assisted walking, demonstrated no reduction in spasticity. Although the modified Ashworth scale was noted as an outcome measure in the methods the authors failed to report the final results associated with this clinical measure.
Granat et al. (1993), in a similar trial of FES-assisted walking in people with longstanding SCI (Frankel C or D), also found reductions in spasticity by employing a pendulum drop test but did not show any change pre- and post-training when considering Ashworth scale scores. Granat et al. (1993) performed the final spasticity assessment 24 hours after the final FES-assisted walking session; thereby ensuring the final outcomes would not be unduly influenced by the short-term effects of muscle stimulation.
Thoumie et al. (1995) examined the effects of a FES-assisted Reciprocating Gait Orthosis II (RGO) on spasticity following a long-term program (i.e., 3-13 months) of gait training. No group results were reported for spasticity although it appeared that no systematic effects were obtained on a customized self-report version of the Ashworth scale. Some subjects (n=7) reported decreases in spasticity in the short-term, while others reported increased spasticity (n=4).
There is level 2 evidence from a single study that hydrotherapy is effective in producing a short-term reduction in spasticity.
There is level 2 evidence from a single study that single bouts of FES-assisted cycling ergometry and similar passive cycling movements are effective in reducing spasticity over the short-term with FES more effective than passive movement.
There is level 4 evidence from three studies that a program of FES-assisted walking acts to reduce ankle spasticity in the short-term (i.e., <24 hours).
There is no evidence describing the length and time course of the treatment effect related to spasticity for hydrotherapy or FES-assisted walking.
- Active exercise interventions such as hydrotherapy and FES-assisted cycling and walking may produce short-term reductions in spasticity.