Spasticity: Yale Medicine Offers Advanced Therapies and Innovative Surgery

Spasticity is a neurological condition, a problem with how the brain sends signals to muscles, that can develop after a brain injury or disorder. It can have a profound effect on mobility.

With this condition, signals from the brain telling a muscle to move can misfire in brief episodes or more persistently—or even constantly in severe cases, causing the muscle to tighten or spasm. A hand clenches until the fingernails press into the palm. A toe points downward until it’s almost impossible to take a step.

Proper care requires a team of specialists and often a variety of treatments, says Yale Medicine plastic surgeon Elspeth Hill, MBChB, PhD. Dr. Hill directs the Yale Adult Spasticity Multidisciplinary Program, which focuses on upper extremities such as arms, hands, fingers, elbows, and shoulders. A keystone of the program is an innovative surgery called hyper-selective denervation—a procedure that weakens overactive nerve signals to specific muscles and can provide lasting relief.

“We’ve gone from having maybe two treatments to offer for spasticity to a menu of 25,” Dr. Hill says. “There’s no cookie-cutter approach. Every patient is different, and we often use a combination of therapies.”

Access to this kind of care, however, has not kept pace with need. Patients who are already coping with serious underlying conditions often navigate a patchwork of specialists. Yale Medicine’s program is one of just a few nationwide to bring together a full team under one roof—experts in plastic surgery, orthopaedics, neurology, neurosurgery, and physiatry who collaborate and treat patients as a group to determine their best care.

“The need is very great,” says Lisa Lattanza, MD, Yale Medicine’s chair of orthopaedic surgery, who specializes in hand and upper extremity surgery. “Many of our patients aren’t able to work or lead active lives. They’re often in pain, with parts of their bodies stuck in positions that make movement, hygiene, and caregiving incredibly difficult.”

Normally, when you move your arm or make a fist, your brain sends a signal telling the muscle to contract—then relax. With spasticity, that signal doesn’t shut off.

“The brain constantly tells the muscle to fire, fire, fire, creating excess tone,” Dr. Hill says. This tightness is velocity-dependent: the faster you try to move, the more the muscle resists.

For some people, spasticity is mild—a stiffness or tightness that still allows movement. In more severe cases, over time the muscle shortens, the joint tightens, and a limb can lock into a fixed position. One common example: a hand clenching so tightly that it becomes difficult to clean the palm or trim fingernails, leading to pain, skin breakdown, and infection. “It hurts when a caregiver tries to help with basic hygiene,” Dr. Hill says.

More than 2 million people in the United States live with spasticity. It can affect all ages, from infants to older adults, and often develops alongside conditions that disrupt normal brain function, including:

• Cerebral palsy
• Multiple sclerosis
• Parkinson’s disease
• Traumatic brain injury
• Spinal cord injury (from car accidents, falls, or other serious trauma)
• Stroke

In each case, the common thread is a disruption in the brain’s ability to regulate muscle movement.

The right approach depends on the muscles involved, the severity and pattern of symptoms, the underlying condition, and the patient’s goals. “We tailor therapy to each individual,” Dr. Hill says.

Treatment options include both nonsurgical and surgical approaches, and they are often combined.

Nonsurgical treatments include:

• Physical and occupational therapy: Often the first step, spasticity therapy can improve range of motion, strength, and function. Casting or bracing may also help support affected limbs.
• Oral medications: Drugs including baclofen, benzodiazepines, dantrolene, and gabapentin can reduce muscle tone throughout the body. Because they are not targeted to specific muscles, they may cause side effects such as drowsiness or generalized weakness.
• Botulinum toxin (Botox) injections: These injections block nerve signals to specific muscles, allowing them to relax. Results are temporary, typically lasting 12 to 16 weeks, and repeat treatments are limited.
• Intrathecal baclofen pump: A small device surgically implanted in the abdomen delivers baclofen medication directly into the fluid surrounding the spinal cord. It is usually reserved for severe spasticity and can provide strong, targeted relief with fewer whole-body side effects than oral medications.
• Cryoneurolysis (nerve freezing): A controlled application of cold to selected nerves reduces the signals reaching the muscle, decreasing spasticity. Results typically last three to six months. This technique can also help predict how a patient might respond to longer-term treatments, including nerve surgery.

Nonsurgical therapies can also help guide surgical decisions. “We might see how the muscle does with and without Botox, and that helps us move toward the right surgical approach,” Dr. Lattanza says. “We might do a selective nerve block using lidocaine to temporarily deaden a nerve so we can see how it would affect mobility if we removed it surgically.”

No. Many patients improve significantly with nonsurgical treatments, and surgery is one option among many.

“There’s no cookbook,” Dr. Lattanza says. “It’s so different from patient to patient—how bad their spasticity is, how they will react to treatment.”

When surgery is appropriate, it may involve more than one technique, such as tendon or muscle lengthening, joint fusion to a functional position, or nerve surgery.

“There are two approaches to surgery,” Dr. Lattanza says. “You can fix it so the muscles can’t pull so hard—by lengthening the tendons and muscles so they don’t have as much strength, which secondarily reduces the spasticity. Or you can take a more direct approach and operate to interrupt the nerves. Sometimes it’s one or the other. Sometimes it’s a combination of both.”

Hyper-selective denervation is a surgical technique that targets the spastic nerves where they enter the muscle—at the precise point where overactive brain signals are being delivered. By selectively reducing those signals, the surgery decreases abnormal muscle tightness without affecting the rest of the body.

“The nerves, when they branch into the muscle, are very, very fine,” says Dr. Hill, who trained internationally to learn the technique. Using microsurgery—which employs a microscope to magnify tiny nerve branches—she identifies and tests each branch individually. “I stimulate them to find the ones that are most overactive or spastic,” she says.

She then selectively reduces those signals. “We take the nerve input to that muscle from 100% down to about 20%,” Dr. Hill explains. “That decreases the constant firing so the person can both move and relax—without fighting the tightness.”

This procedure is most commonly used in the upper extremities, where spasticity can severely limit independence—affecting daily activities like dressing, eating, and using a wheelchair. The procedure can sometimes be done using minimally invasive techniques, depending on the location and complexity of the problem being treated.

Occupational therapy helps patients navigate the practical challenges of mobility and daily function—and in some cases, it helps them and their care team choose the most appropriate treatment.

“We often discuss which treatment is most likely to help a patient,” says Chelsea Taylor, OTD, an occupational therapist and certified hand therapist on the Yale Medicine spasticity team. “It often comes down to function and achieving the best quality of life.”

Because many patients have multiple spasticity issues, occupational therapy is frequently combined with other treatments. For example, relief for a spastic thumb may mean choosing between a muscle-lengthening procedure that requires minimal splinting or a bone fusion that requires six to eight weeks in a custom splint—the latter could be a difficult choice for someone who relies on hand controls to operate a wheelchair, Taylor notes.

The Yale Medicine team also provides orthoses, which are external medical devices such as braces or splints that are custom-made or prefabricated before surgery to assess how they may support function, Taylor says. “This can help the patient and surgeons decide on the most effective surgical plan," she says.

In children, spasticity is most commonly caused by cerebral palsy, though it can also result from other conditions including meningitis, premature birth, stroke, and traumatic brain injury.

Children whose spasticity stems from a condition present at birth often adapt remarkably well, since they have never experienced movement any other way, says Dr. Lattanza, who treats children through the Yale Medicine Pediatric Spasticity Program.

As with adults, spasticity in children exists on a wide spectrum—from mild involvement of a single limb to more severe, whole-body stiffness that may require a wheelchair.

While many of the same nonsurgical options apply, because children are still growing, surgical considerations are somewhat different. “If you lengthen a muscle at age 8 or 9, it may tighten again as the child grows, and joint fusion options are not available until growth is complete because we do not want to interfere with growth of the limb,” Dr. Lattanza explains. The goal is to support development—not interfere with it. However, there are still good surgical solutions for children, and treatment is tailored to the problem and functional goals, keeping growth and development in mind, she says.

The impact of spasticity treatments can be significant, and even modest improvements often matter a great deal to patients.

“There are things I would never have expected,” says Dr. Hill. “I’ve had patients tell me they sleep better because their arm is more comfortable, or that they can walk without aids because they can now balance better, as their spastic arm is now calm. One patient felt intense pain when a caregiver tried to lift his arms to dress him. Surgery allowed him to move his arm normally.”

Goals vary widely. Some patients are highly independent and want more precise, controlled movement. Others rely on caregivers and want relief from discomfort—easier dressing, less pain during bathing, the ability to lift an arm. One patient who loved crafts could no longer pinch her fingers together to use scissors or pick up small objects. Surgery involving muscle lengthening and repositioning of her thumb and index finger restored that ability.

“That may seem like a small thing to some people, but to her it was really a big deal,” Dr. Lattanza says. “In fact, there is almost no one that we have operated on who didn’t think what we did helped them in some way. Even if a person has very little function, giving back a little bit can be a lot.”

If muscle stiffness, tightness, or involuntary contractions are interfering with daily life—affecting movement, hygiene, comfort, or the ability to receive care—it is worth speaking with a physician. A specialized hand and upper extremity surgeon, physiatrist (a specialist in physical medicine and rehabilitation), neurologist, or a multidisciplinary spasticity program like Yale Medicine’s can help evaluate symptoms and identify appropriate next steps.

Early treatment may prevent spasticity from worsening and can help preserve function over time.

“When you bring the right specialists together around one patient, the options open up,” Dr. Lattanza says. “That’s really what this program is built to do.”