Medical, cognitive, behavioral, and psychosocial issues are often considered as key factors in the rehabilitation of individuals who have sustained traumatic brain injury (TBI). However, data from the TBI Model Systems 1 has indicated that 25% of people admitted to inpatient rehabilitation units secondary to TBI have some evidence of hypertonicity or spasticity. The consequences of spasticity can be debilitating, causing significant pain, limiting personal hygiene and self-care skills, and placing a greater burden on caregivers. For individuals who have limited mobility secondary to their injury, spasticity may interfere with proper positioning and performance of hygiene tasks. In other cases, issues such as performance of activities of daily living, transfers, and ambulation may be negatively affected by the presence of spasticity. Numerous assessment strategies and treatment modalities have been developed for the management of spasticity; however, it can be challenging for the clinicians who have to choose among these options. As a result, management of spasticity after TBI remains one of the most challenging issues that confront clinicians managing individuals who have sustained trauma. We are pleased to present these articles in this issue of the Journal of Head Trauma Rehabilitation that focus on this important clinical issue and we hope this volume will help clinicians in their decision-making process.

In the first article, Dr Zafonte and colleagues address the vexing issue of spasticity management in the intensive care unit and acute care setting. Treatment delivered in those settings can be very problematic as medical instability and impaired level of consciousness complicate the decision-making process as to management of spasticity. This is a critical issue as a failure to deal with hypertonicity early on may doom future rehabilitation efforts. The authors review the limited literature that is available and give guidance to clinicians through a case example.

Dr Meythaler et al report one of the only studies that demonstrate a benefit from oral administration of baclofen in patients whose spasticity is secondary to brain injury. While this study is not a controlled study but a convenience sample, it is an addition to the literature by demonstrating statistical significance in the reduction of lower extremity spasticity; however, its clinical significance is unknown. The authors also review theoretical issues of why baclofen may be more efficacious in the lower rather than the upper extremities.

In his article entitled "Choosing Upper Limb Muscles for Focal Intervention After Traumatic Brain Injury," Dr Mayer discusses the relationship between the different clinical presentations of spasticity patterns in the upper extremity and the muscles that are involved. In addition he shares his clinical perspective regarding therapeutic goal selection in the patient with spasticity. In a related article, Dr Esquenazi discusses the various pathological spasticity patterns that affect gait. Using diagrams and dynamic EMG data, his article will facilitate the reader's understanding of the relationship between abnormalities in muscle kinesiology, spasticity, and clinical presentation.

In their article, Drs Keenan and Mehta discuss the numerous clinical options that are available to the orthopedist in the management of the neuro-orthopedic problems that face individuals who have sustained a TBI. Starting the discussion with the general principles that they use in their clinical practice, they then discuss the different conditions and treatment options that are commonly seen by orthopedic surgeons caring for patients with TBI. This includes the areas of fracture malunion, heterotopic ossification, adhesive capsulitis, shoulder subluxation, rotator cuff tears as well as spasticity.

In the final article, Elovic and colleagues address the very complicated area of outcome assessment of spasticity. The article is a review of the measurement tools used in numerous studies and suggests a hierarchical arrangement that may assist clinicians in the assessment process of spasticity.

The editors thank the editorial board in choosing them to assemble this volume and to address this important issue. They also express their gratitude to the authors and reviewers who gave of their time to make this task a reality.

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