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Should mirror movements modify therapeutic strategies for unilateral spastic cerebral palsy?

One of the hallmark symptoms of the most common types of cerebral palsy is spasticity. Spasticity is often defined as increased, involuntary, velocity-dependent muscle tone that causes resistance to movement – or a minor variation of this definition. Spasticity negatively impacts function and quality of life. Many treatment decisions regarding medication and surgery are based on the severity of spasticity and whether or not it is stable, improving, or worsening over time. Ultimately, improved function and a higher quality of life for individuals and caregivers is the primary goal of interventions. Unfortunately, it is very difficult to objectively and reliably quantify spasticity. Since there is not a reliable criterion standard for assessing spasticity, the clinician is often dependent upon the patient’s or the caregiver’s perception of muscle tone changes over time. Regrettably, there can be a strong placebo component to the perception of treatment. Without sensitive and reliable assessments that can detect true changes in spasticity, clinicians are left relying on biased perceptions of patients, caregivers, and our own personal biases. Spasticity scales such as the Modified Ashworth Scale are what clinicians currently rely on to make medical decisions regarding medication changes and even surgical interventions for spasticity, despite limited objectivity. The article by Sloot et al. further highlights the need for more objective information regarding spasticity and spasticity assessments. The findings even suggest that the definition of spasticity may be more accurately defined as increased, involuntary, acceleration-dependent muscle tone that causes resistance to movement. This difference is an important distinction that needs to be considered in developing models as well as objective assessments of spasticity. Many groups have attempted and continue to work towards reliable and clinically meaningful objective measurements and assessments of spasticity to guide patient care and medical decision-making. Objective assessments will need to be able to assess not only a single joint (as in the article by Sloot et al.), but rather multiple upper and lower limb joints as well as functional activities such as gait. In addition, the ability to vary the velocity and acceleration of joint movement will need to be accounted for. Objective assessments will improve decision-making with regard to medication management, dosing, and surgery. This will help to avoid waste and risk such as medication titration when no objective clinical advantage can be observed.