Spasticity: assessment and conservative PT management

1. Case. A 58-year-old woman, 7 months post-stroke. Right elbow flexor Modified Ashworth Scale (MAS) 2, wrist flexors MAS 1+. She reports difficulty with hygiene under the elbow and donning sleeves. She is followed by physiatry, who started oral baclofen last month.

2. CPG section. AHA/ASA 2016: for focal spasticity that limits function or hygiene, botulinum toxin type A is recommended (Class I, Level A). PT scope: stretching, splinting, positioning, task practice, and adjunctive modalities. The MAS (Bohannon RW, Smith MB. *Phys Ther*. 1987;67:206–207) and Modified Tardieu Scale (MTS) are the standard clinical tools; inter-rater reliability is acceptable at the elbow with experienced raters, but variable across joints (Fleuren JF et al., *J Neurol Neurosurg Psychiatry*. 2010;81:46–52).

3. Reasoning walkthrough. Spasticity alone is not the rehabilitation target; the functional consequence is. Document the activity limitation (hygiene, dressing) and the impairment (MAS, MTS, passive ROM). PT-scope interventions with reasonable evidence: prolonged stretching/positioning, task practice that recruits the antagonist, and serial casting in selected cases. Coordinate with physiatry around BoNT-A timing — PT in the 2–6 week window post-injection capitalizes on reduced overactivity. Splinting evidence for the wrist/hand is mixed (Tyson SF, Kent RM. *Cochrane*. 2011); reserve for clear functional indications.

4. Outcome measure. MAS, MTS, passive ROM, and a functional anchor (timed donning of a button-down shirt or a self-reported DASH item). MAS is ordinal — do not average or perform parametric statistics on it. Report by joint and side, before and after intervention.