The Practical Management of Spasticity in Children and Adults.

The Practical Management of Spasticity in Children and Adults

Edited by Glenn MB, Whyte J. Philadelphia, PA 19355, Lea & Febiger, 1990, cloth, 325 pp, illus, $39.50

According to the editors of this text, spasticity is one of the most common and most challenging problems confronting rehabilitation professionals. The editors rightly note that, even though research is bringing us closer to a full explanation of the syndrome (and our ability to influence it), our understanding of the syndrome remains limited.

The stated purpose of this book is to provide a diverse view of the management of spasticity. To accomplish this end, the editors selected contributors who represent a broad range of rehabilitation professions. Many of these contributors are physicians, physical therapists, and occupational therapists.

The authors present a series of definitions in the introduction, but are careful to note that there is no universal agreement about the terms readers will encounter in the text. They do state, however, that the contributors to the book reached agreement on the definitions presented. This effort is highly commendable. Setting the stage in this way is vitally important if readers are to grasp the context and underlying premises of a work.

The book begins with a presentation of the neurophysiology of spasticity. Most of this chapter focuses on the various reflexes that regulate motoneurons; only a short discussion of impaired motor control is included. The chapter on neurophysiologic testing in spasticity explores both active and passive electromyographic findings of patients who have spasticity. These measures also can be used in evaluation procedures in more sophisticated laboratory settings. Clinicians may discover that these findings provide insight into some of the motor behaviors exhibited by patients who have neuromuscular dysfunction and who might also have spasticity. For instance, the rate of motor unit firing may be reduced in such patients, and motor unit activity might be prolonged in certain muscles during movement. The author could have included more detail here, to provide practitioners with a greater understanding of such motor behaviors and their role in evaluation.

Some theories of motor control are explored briefly in the chapter entitled "Motor Learning and Relearning," although no clear relationship between such theories and spasticity has been elucidated. In their discussion of clinical perspectives of remediation, the authors of this chapter analyze neurophysiological "approaches" like PNF, Bobath, and Brunnstrom. Unfortunately, they treat these as specific entities, discussing their time-worn use of developmental sequence; facilitation and inhibition patterns; and reflexes, synergies, and associated reactions. It would have been helpful if the authors had instead explored a view of treatment in which aspects or components of these approaches are seen as contributing to the motor learning schemes suggested by more recent research.

The authors of the chapter on evaluation of spasticity discuss its effect on motor function. They also discuss various instruments and tests and describe variables that may be measured in patients with spasticity, such as resistance to passive movement.

More importantly, they suggest that there may be a hierarchy of measurement variables, of which the most significant are functional abilities and aspects of voluntary movements. The authors discuss in a limited fashion the possibility that spasticity may be involved to only a small degree in an actual cause-effect relationship with movement abnormalities (ie, patients who have spasticity may also have problems with movement speed, synergy construction, excessive or unwanted co-contraction, and muscular weakness). Thus, the spasticity itself, by definition a passive phenomenon, may not be what should be emphasized in treatment.

Each of the remaining chapters in the book is devoted to a thorough discussion of one of these more traditional approaches often used to treat patients with spasticity: physical modalities; positioning; casting and splinting; dynamic casting and orthotics; and pharmacologic, neurosurgical, and orthopedic management. Although this text is about spasticity, there is perhaps an overemphasis on it. A chapter on other elements that contribute to the movement dysfunction found in patients who also have spasticity would have provided a more balanced perspective. Two case-study presentations complete the book.

This book is indexed, nicely illustrated, and generally well-written. I recommend it to practicing therapists who are involved with neurologically impaired patients or who wish to read a relatively thorough discussion of spasticity and spasticity management. Although the material is appropriate for physical therapy students, it may be too extensive to be used as a classroom textbook.

Carolyn Crutchfield, EdD Georgia State University Atlanta, Ga