Managing Muscle Tightness (Spasticity)

General Principles

Treatments aimed at reducing muscle tightness are planned with a step-by-step approach and are always carried out together with physiotherapy. The key question is this: Is this spasticity really causing a problem, or is it — as in some situations — actually helping the child stand to some degree?

I want to emphasize that spasticity should not always be seen as the "enemy"; in some children, a certain degree of tightness, especially in the leg muscles, can give the weak muscles a kind of "natural support" while standing. For this reason, the goal is not to "eliminate spasticity completely" but to "tune" it to the level that best optimizes function.

Physical and Conservative Methods

Stretching exercises, proper positioning, serial casting, and night splints are the basic conservative methods, and in mild-to-moderate spasticity they may be enough on their own.

Regular use of night splints serves a different purpose from splints worn during the day: instead of supporting function during the day, they aim to slow the development of contractures by holding the joint in a stretched position overnight. It is important not to confuse these two types of splint.

Medications Taken by Mouth (Oral Medications)

In widespread spasticity or dystonia, oral muscle relaxants (such as baclofen, alpha-2 agonists like tizanidine, benzodiazepines, dantrolene, and anticholinergics such as trihexyphenidyl for dystonia) may be used. A limitation these medications share is that, because they act on the whole body, side effects such as sedation and weakness can be limiting. Which medication is right and at what dose is entirely an individual decision and should be determined by your doctor; these medications should never be stopped suddenly.

Botulinum Toxin

Botulinum toxin type A is the most commonly used interventional method for managing focal spasticity; injected into the target muscle, it provides a reversible muscle relaxation lasting about 3-6 months. Its uses include ankle spasticity, adductor spasticity, upper-limb spasticity, painful muscle spasms, and excess drooling.

Botulinum toxin is not a treatment on its own; it is always applied together with a goal-directed therapy program. The real gain comes from the active rehabilitation carried out during the temporary window of relaxation the toxin provides.

The frequency of repeating botulinum toxin injections is usually limited to intervals of at least 12 weeks; this is because more frequent application can increase the risk of the body developing neutralizing antibodies against the toxin and can reduce the effectiveness of the injections over time.

Intrathecal Baclofen (ITB)

In severe, widespread spasticity and/or dystonia, when oral medications are not enough, an intrathecal baclofen pump may be considered. Through a small pump placed in the abdominal wall, the medication is delivered directly into the spinal fluid; in this way, effective relaxation can be achieved with an amount far below the oral dose.

In children carrying an ITB pump, the pump's refill dates and battery life must be followed regularly; missing this follow-up can lead to a serious risk, like the treatment being stopped suddenly. For this reason, it is very important not to miss the pump follow-up appointments.

Surgical Neuromodulation: Selective Dorsal Rhizotomy

In some selected children with predominantly leg spasticity, selective dorsal rhizotomy (SDR) — in which certain sensory nerve roots in the spinal cord are selectively cut — may be performed. SDR is an irreversible intervention; which child will benefit from this method must be carefully evaluated by a multidisciplinary team.

The rehabilitation process after SDR is intensive and long; it generally requires an inpatient stay in the first weeks after surgery, followed by months of intensive outpatient physiotherapy. This process asks for great patience and motivation from both the family and the child; it is important to evaluate in advance with your surgical team whether you are ready for this intensive commitment.

A Holistic Approach to Choosing Treatment

Which spasticity treatment is right should be decided by a multidisciplinary team, taking into account the distribution of the spasticity, the child's age, functional goals, accompanying problems, and the family's preferences. In these decisions, your observations must always be heard as well.

Managing Expectations After Treatment

After any spasticity treatment (botulinum toxin, oral medication, surgery), it is important for families to have a realistic timeline. For example, the effect of botulinum toxin usually begins a few days after the injection and becomes clearer over the following weeks; intensified physiotherapy during this window is critically important. Clarifying your expectations with your doctor in advance prevents disappointment after treatment.

Making Painful Injections Easier

In treatments that require injections, such as botulinum toxin, methods such as topical anesthetic creams, distraction techniques (video, toys), or, if needed, light sedation can be used to reduce the child's pain and anxiety. Talking about this with your doctor before the injection can make the procedure more comfortable for both your child and you.

Telling Spasticity Apart from Dystonia

Spasticity (muscle resistance that increases with the speed of movement) and dystonia (involuntary, sustained muscle contractions) can sometimes be confused, but the treatment approaches differ. Making this distinction correctly is critical for choosing the right treatment; in some children both may be present together (mixed tone disorder), which can make treatment planning more complex and requires the assessment of an experienced specialist.

Monitoring Tone Fluctuations Day to Day

In some children, muscle tone can fluctuate noticeably during the day (depending on factors such as fatigue, excitement, or illness). Noting these fluctuations — for example, observing whether the tone is tighter in the morning or the evening — provides useful information both for planning the timing of treatment (such as which time of day to give an oral medication dose) and for determining when therapy sessions will be most effective.

Family Expectations in Spasticity Treatment

Families' expectation of spasticity treatment can sometimes be that "the tone will return completely to normal"; the realistic goal, however, is usually to reduce the excess tone that limits function or causes pain, not a full "normalization." Clarifying this expectation before starting treatment helps the results be evaluated correctly.

Improving Adherence to the Home Exercise Program

Building stretching exercises into the daily routine (after a bath, while getting into pajamas) can be more sustainable than creating a separate "exercise time." Short, frequent repetitions are generally better tolerated than long, infrequent sessions and turn into a habit more easily.