Review article Breakthroughs in the spasticity management: Are non-pharmacological treatments the future? Antonino Naro a , Antonino Leo a , Margherita Russo a , Carmela Casella b , Antonio Buda a , Aurelio Crespantini a , Bruno Porcari a , Luigi Carioti a , Luana Billeri a , Alessia Bramanti a , Placido Bramanti a , Rocco Salvatore Calabrò a,⇑ a IRCCS Centro Neurolesi ‘‘Bonino-Pulejo”, Messina, Italy b Stroke Unit, University of Messina, Italy article info Article history: Received 2 December 2016 Accepted 12 February 2017 Available online xxxx Keywords: Repetitive transcranial magnetic stimulation Transcranial direct current stimulation Stroke Multiple sclerosis Spinal cord injury abstract The present paper aims at providing an objective narrative review of the existing non-pharmacological treatments for spasticity. Whereas pharmacologic and conventional physiotherapy approaches result well effective in managing spasticity due to stroke, multiple sclerosis, traumatic brain injury, cerebral palsy and incomplete spinal cord injury, the real usefulness of the non-pharmacological ones is still debated. We performed a narrative literature review of the contribution of non-pharmacological treat- ments to spasticity management, focusing on the role of non-invasive neurostimulation protocols (NINM). Spasticity therapeutic options available to the physicians include various pharmacological and non-pharmacological approaches (including NINM and vibration therapy), aimed at achieving functional goals for patients and their caregivers. A successful treatment of spasticity depends on a clear compre- hension of the underlying pathophysiology, the natural history, and the impact on patient’s perfor- mances. Even though further studies aimed at validating non-pharmacological treatments for spasticity should be fostered, there is growing evidence supporting the usefulness of non- pharmacologic approaches in significantly helping conventional treatments (physiotherapy and drugs) to reduce spasticity and improving patient’s quality of life. Hence, non-pharmacological treatments should be considered as a crucial part of an effective management of spasticity. Ó 2017 Elsevier Ltd. All rights reserved. 1. Introduction Spasticity is defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes, which results from an abnormal intra-spinal processing of primary afferent inputs. Such motor disorder follows a central nervous system (CNS) damage that dissociates the motor and sensory components of the diastaltic arch, thus inducing a segmental hyper-excitability [1]. Spasticity can be associated with a variety of symptoms and signs belonging to upper motor neuron syndrome, including clo- nus, dystonia (muscle constriction in the absence of any voluntary movement), extensor or flexor spasms, spastic co-contraction (con- traction of both the agonist and antagonist muscles resulting from an abnormal pattern of commands in the descending supra-spinal pathway), abnormal reflex responses (exaggerated deep tendon reflexes and associated reaction), loss of dexterity, muscle fatigue, weakness, stiffness, fibrosis, and atrophy [2–6]. Many CNS diseases, including stroke, multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury (SCI), can provoke spas- ticity. Three main lesion sites have been suggested to induce spas- ticity: the brainstem, the cerebral cortex (in primary, secondary and supplementary motor areas) and the spinal cord (pyramidal tract) [7]. Of note, spasticity in MS is believed to be due to either axonal degeneration or demyelination within specific descending tracts, or both, thus leading to an inhibitory/excitatory imbalance at spinal network level [8]. Initially, CNS damage determines a local anarchic neuronal reorganization and, as a consequence, a dysfunctional and mal- adaptive connectivity among several brain structures, including supplementary motor, cingulate motor, premotor, posterior and inferior parietal areas, and cerebellum [9]. These pathologic re- arrangements contribute to subcortical hyper-excitability, leading to an increased muscle activity and exaggerated spinal reflex responses to peripheral stimulation [7]. Such hyperactivity may depend on: i) disinhibition of the normal reflex activity (deep ten- http://dx.doi.org/10.1016/j.jocn.2017.02.044 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved. ⇑ Corresponding author at: IRCCS Centro Neurolesi ‘‘Bonino-Pulejo”, S.S. 113, Contrada Casazza, 98124 Messina, Italy. Fax: +39 9060128950. E-mail address: salbro77@tiscali.it (R. Salvatore Calabrò). Journal of Clinical Neuroscience xxx (2017) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Naro A et al. Breakthroughs in the spasticity management: Are non-pharmacological treatments the future? J Clin Neu- rosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.02.044