Key Point 

• The ways central nervous system injury leads to spasticity are still being explored. Massage therapy may help, if it is done with care.

Spasticity—the progressive, involuntary tightening of voluntary muscles—can be painful, limiting, and eventually permanent. Can bodywork influence spasticity? It’s an interesting question. 

Spasticity, hypertonicity, and rigidity are three distinct issues (see “Muscle Tone Vocabulary,” page 81). Logically, manual therapy should not substantially impact damage to the central nervous system (CNS) that leads to motor neuron deficits. Yet many massage therapists report improvements in pain, function, and range of motion for their clients affected by spasticity. And research findings, while limited, support those observations.

In this article, we take a closer look at spasticity: what situations cause it, what happens to the involved nerves, muscles, and connective tissues, and how that information might shape some decisions about massage therapy.

Anatomy Review

The CNS comprises the brain and spinal cord, and the peripheral nervous system (PNS) comprises the cranial and spinal nerves. Each of those nerves is composed of thousands of long nerve cell fibers or neurons. The motor and sensory neurons of the PNS have extensions that reach into the spinal cord to synapse with ascending (sensory) neurons going toward the brain and descending (motor) neurons coming from the brain, but the terminal points of motor and sensory nerve fibers in the PNS are found in the skin, connective tissue, muscles, and organs. In this discussion, we will focus on the motor neurons of the PNS, all of which terminate in either muscle tissue or glands.

When we decide to move, for instance to shift in our seat or scratch our nose, the brain initiates voluntary motor messages. These are passed on to motor neurons in the descending tracts of the spinal cord, which pass them onto the spinal nerves, where they are transmitted to muscles at motor end plates. Motor fibers in the brain and spinal cord are called upper motor neurons (UMNs). Motor fibers in the PNS are called lower motor neurons (LMNs) (Image 1).

It is useful to distinguish between these neurons because injury to UMNs usually reflects as spasticity and the very high tone we see with stroke, brain injury, cerebral palsy, spinal cord injury, multiple sclerosis, and other issues. By contrast, injury to LMNs shows as the opposite: Muscles are weak and flaccid, as we see with Bell’s palsy, which is related to irritation of the facial nerve—part of the PNS. 

What Is Spasticity?

What happens neurologically when spasticity develops? It appears that this is the result of an imbalance between excitatory and inhibitory neurotransmitters in the CNS that controls the passing of messages to lower motor neurons. This imbalance has a profound effect on the action of proprioceptors that establish the stretch reflex, our protective tightening response against the sudden stretching of a muscle or tendon.  

Neurologists do not universally agree on some of the details of spasticity, and some of our understanding of this topic may evolve as we learn more about CNS function. By definition, spasticity is “a velocity- dependent increase in muscle tone caused by the increased excitability of the muscle stretch reflex.”¹ In other words, the stretch reflex is hyper-reactive, leading to excessive tightening in key muscle groups, especially flexors. Muscles become resistant to any stretching at all, but especially to fast stretching. Other signs may also be present, including clonus (involuntary, rhythmic muscular contractions) and painful spasms in flexors and extensors.   

People who have spastic muscles often still have sensation, unless it is impaired for some other reason. A complete spinal cord injury that severs both ascending and descending tracts is a situation where a person might lose most or all sensation, for example. But most of the time some sensation is present, although proprioception is often distorted and the tension and tissue changes in muscles, tendons, ligaments, and joints can be painful.

Despite decades of study and many breakthroughs in the treatment of CNS injuries, the exact relationships and patterns of dysfunction in spasticity are not fully understood. And this leaves open some questions about the potential role of bodywork for people who live with this challenge. 

Repercussions of CNS Injury

Spasticity can be transient, but its impact on the body can become permanent. Again, this process is complex and probably varies from one person to another, but we see that untreated or undertreated spasticity promotes several pathologic changes that become difficult to reverse.

Proprioceptive Distortion

People with CNS injuries have hyperexaggerated stretch reflexes. Usually this results in tight flexors and weak extensors, especially in the arms, wrists, and hands. In the lower extremity, the patterns are a bit different, but hip flexors, knee flexors, and foot inverters are usually dominant. As noted, this begins with CNS dysfunction. But the proprioceptors that set muscle tone and respond to gravitational force to help us maintain balance can be “tricked” into adopting these unhealthy levels of tone as normal. In this way, the progressive tightening we see with spasticity may also be influenced by proprioceptive messages from the PNS. The good news here is that at least some of this can be undone with careful and knowledgeable manual therapy.

Fibrosis and Contractures

When a muscle is constantly tight and not overturning wastes and nutrients, its connective tissue layers may thicken. Over time the muscle cells may atrophy while the fascial membranes that permeate throughout muscles become thicker, denser, and stiffer, limiting range of motion and freedom of movement. This may not be a reversible change.

Osteoporosis, Infections, and Other Complications

When a part of the body cannot move or do work, the bone density in that area often decreases. This leads first to osteopenia—bone loss—and eventually to osteoporosis and bones that are brittle and easy to break. Other complications of long-term spasticity depend on the extent of the affected areas but can include pain; a risk of deep vein thrombosis and pulmonary embolism; pressure sores, secondary infection, and sepsis; urinary catheterization and the possibility of urinary tract and kidney infections; and much more. 

Spasticity and paralysis occur on a continuum of severity. Some people are affected only minimally, and others are completely debilitated. In either situation, along with chronic pain and loss of function, it is possible to predict that most people with a history of CNS injuries will also experience depression
and/or anxiety and the mourning and other adjustments that must occur when a health challenge affects independence. Being able to find and keep a job, maintain a social support system, pursue much-loved hobbies, and feel like a contributing member of society can feel like unattainable goals. On a more personal and practical level, bladder and bowel continence may be compromised or lost. It may be necessary to hire aids to help with self-care. Equipment like customized wheelchairs can be prohibitively expensive. Add to this the challenges that people face with access to basic health services or even to buildings where they need to go, and now these challenges can be a full-time job and can lead to early aging and shortened lifespans. 

Bodywork May Help

A glance at the resources on page 83 suggests we have some depth of evidence about manual therapies and spastic paralysis. In truth, most of the studies so far have been small scale and their study design sometimes might not hold up against rigorous scrutiny. However, a recurring theme emerges from this work: Massage therapy, including proprioceptive neuromuscular facilitation, myofascial release, and other techniques, appears to be both safe and helpful for people with spasticity. It is even more effective when combined with conventional treatment, which is likely to involve physical and occupational therapy and medications for pain and muscle tightness. 

Refinements, like what kind of proprioceptive neuromuscular facilitation or when to start myofascial release, and other details vary. The overall takeaway is that if you have a client with spasticity and you’re worried about how to bring the best to your table, do these things:

• Ask them what they hope to achieve with massage and base your decisions around those goals.

• Ask them what kinds of activities, especially stretching, make their symptoms worse and tell
them to avoid doing those activities or do them
with great care.

• Ask them about their medications and side effects and accommodate for those. For instance, muscle relaxants and pain relievers will create inaccurate tissue responses to pressure or movement, so don’t overdo that kind of work.

• Ask them about their sensation and be aware that areas with reduced sensation or numbness require more conservative touch.

• Be in communication with them throughout the session to ensure you aren’t causing any inadvertent discomfort. 

• Check in at the end and after your session to see how they are and whether your work helped them toward their goals. Use that information to help shape your next session. 

A lot of people in this country live with the repercussions of some kind of CNS problem. Massage therapy won’t reverse the process or completely restore lost function, but we can bring pain relief, more mobility, and improved mental and emotional states for the many people who are hoping to receive the benefits of our work. Those improvements won’t be permanent, but it seems clear that educated, careful, compassionate bodywork can be an important part of self-care for people who have spasticity. 

Note

1. Angshuman Mukherjee and Ambar Chakravarty, “Spasticity Mechanisms—for the Clinician,” Frontiers in Neurology 1 (December 2010): 149. https://doi.org/10.3389/fneur.2010.00149.  

Resources 

Adams, M. M., and A. L Hicks. “Spasticity After Spinal Cord Injury.” Spinal Cord 43, no. 10 (October 2005): 577–86. https://doi.org/10.1038/sj.sc.3101757.

Backus, D. et al. “Impact of Massage Therapy on Fatigue, Pain, and Spasticity in People with Multiple Sclerosis: A Pilot Study.” International Journal of Therapeutic Massage & Bodywork 9, no. 4 (December 2016): 4–13. https://doi.org/10.3822/ijtmb.v9i4.327.

Bingöl, H., E. Akaras, and H. Kocaman. “The Effects of Massage Therapy on Symptoms Related Cerebral Palsy in Children with Cerebral Palsy: A Systematic Review.” Journal of Clinical Medicine of Kazakhstan 4, no. 58 (2020): 6–14. https://doi.org/10.23950/1812-2892-JCMK-00775.

De Britto, V. L. S., R. Correa, and M. B. Vincent. “Proprioceptive Neuromuscular Facilitation in HTLV-I-Associated Myelopathy/Tropical Spastic Paraparesis.” Revista da Sociedade Brasileira de Medicina Tropical 47, no. 1 (Jan-Feb 2014): 24–9. https://doi.org/10.1590/0037-8682-0245-2013.

Kruse, A. et al. “Acute Effects of Static and Proprioceptive Neuromuscular Facilitation Stretching of the Plantar Flexors on Ankle Range of Motion and Muscle-Tendon Behavior in Children with Spastic Cerebral Palsy—A Randomized Clinical Trial.” International Journal of Environmental Research and Public Health 19, no. 18 (September 2022): 11599. https://doi.org/10.3390/ijerph191811599.

Mahmood, Q., S. Habibullah, and M. N. Babur. “Potential Effects of Traditional Massage on Spasticity and Gross Motor Function in Children with Spastic Cerebral Palsy: A Randomized Controlled Trial.” Pakistan Journal of Medical Sciences 35, no. 5 (September-October 2019): 1210–5. https://doi.org/10.12669/pjms.35.5.478.

Parikh, R. J. et al. “Effects of Myofascial Release with Tennis Ball on Spasticity and Motor Functions of Upper Limb in Patients with Chronic Stroke: A Randomized Controlled Trial.” Medicine 101, no. 31 (August 2022): e29926. https://doi.org/10.1097/MD.0000000000029926.

Physiopedia. “Spasticity.” Accessed August 2024. www.physio-pedia.com/Spasticity.

Pilitsis, J. G. American Association of Neurological Surgeons. “Spasticity.” Accessed August 2024. www.aans.org/patients/conditions-treatments/spasticity. 

Rasool, F. et al. “The Effect of Deep Cross Friction Massage on Spasticity of Children with Cerebral Palsy: A Double-Blind Randomised Controlled Trial.” The Journal of the Pakistan Medical Association 67, no. 1 (January 2017): 87–91. https://pubmed.ncbi.nlm.nih.gov/28065961.

Smedes, F., and L. Giacometti da Silva. “Motor Learning with the PNF-Concept, an Alternative to Constrained Induced Movement Therapy in a Patient After a Stroke: A Case Report.” Journal of Bodywork and Movement Therapies 23, no. 3 (July 2019): 622–7. https://doi.org/10.1016/j.jbmt.2018.05.003.

Trompetto, C. et al. “Pathophysiology of Spasticity: Implications for Neurorehabilitation.” BioMed Research International (October 2014): 354906. https://doi.org/10.1155/2014/354906.

Yang, J.-M., and S. Kim. “Correlation of Knee Proprioception with Muscle Strength and Spasticity in Stroke Patients.” Journal of Physical Therapy Science 27, no. 9 (2015): 2705–8. https://doi.org/10.1589/jpts.27.2705.

Muscle Tone Vocabulary

Several terms refer to muscles that are tighter than ideal, but they don’t all have the same contributing factors. Following is a short vocabulary list to differentiate between different types of muscle tightness.

Tone

For our purposes, the phrase muscle tone refers to the percentage of motor units that are engaged when a muscle is at rest. If a resting muscle feels “tight,” it may mean that more fibers are working than necessary. This can be due to stress, postural habits, and the influence of proprioceptors that determine (sometimes inaccurately) how much tone is needed at rest.

Hypertonicity

We often use the term hypertonic to describe muscles that feel tight and stiff when they are at rest. This is accurate, but the technical definition of hypertonicity is broader and can encompass all kinds of pathologically increased levels of tone, including dystonia, rigidity, and spasticity.

Rigidity

Rigidity is chronic muscle stiffness and tightness that is not affected by the speed of movement. It can be caused by stress, but we often use this term to refer to the kind of ongoing and pathologic increase in muscle tone seen with Parkinson’s disease or other neurological problems. 

Spasticity

When upper motor neurons are damaged through trauma or disease, spasticity may develop in the extremities. It differs from rigidity because it is connected to velocity: The faster a part of the body moves, the tighter the resistance becomes. The tension between flexors and extensors often leads to a “clasp-knife” effect where the flexors tighten and the extensors give up.