Reflective Article on a plenary session presented by Dr Anton Pick. This article was submitted as a condition of the author receiving a bursary place at PMG2025

I was incredibly grateful to be offered a bursary place by the PMG committee to attend the 2025 conference. As someone new to the posture and mobility sector - having come from a background in the Scientist Training Programme with a focus on medical device risk management within a large acute trust - this opportunity was invaluable. It offered me exposure to the broader landscape of the industry and allowed me to learn from some of the leading professionals working within the sector. Gaining insight into seating considerations from a more therapy-led perspective was particularly informative.

The plenary session by Dr Anton Pick, titled "Posture and Mobility: Does Spasticity Even Matter?", stood out as especially thought-provoking. Prior to this session, my understanding of spasticity was relatively limited, particularly in the context of how it can and should be accommodated in postural support and seating solutions.

Dr Pick began by tracing the development of the clinical definition of spasticity, before moving into a nuanced breakdown of its functional components. He introduced three distinct patterns or sources of spasticity: impaired command, dysregulated control, and diminished compliance. This framework offered a new way of viewing spasticity, not as a single entity to be managed uniformly, but as a spectrum of underlying mechanisms that may each require a different therapeutic or postural approach.

In current wheelchair and seating provision, spasticity is often approached as a single, uniform challenge which is typically managed through compensatory strategies. These may include using contoured seating systems, laterals, and dynamic components to counteract extensor forces or fluctuating tone [1] [2]. However, this standard approach often treats spasticity as a mechanical issue to be contained and dealt with, rather than as a variable response. From my rather limited experience and through reviewing the surrounding literature, clinical outcomes with this approach are mixed. While many individuals experience improved stability and reduced risk of pressure injury or falls [3], others find that rigid containment strategies exacerbate discomfort or trigger other reflexive responses [4] [5]. Moreover, spasticity-related postural changes may still progress over time, particularly if the underlying causes, such as poorly managed tone or motor control issues, are not fully explored or treated.

The majority of the preceding literature focuses on managing spasticity and does not discuss the potential therapeutic benefits of seating for spasticity. Dr Pick’s talk offers an alternative perspective, which raises the question of whether a more tailored approach would yield better functional and comfort-based outcomes. Differentiating between impaired command, dysregulated control, and diminished compliance might allow clinicians to better match seating strategies or refer for other medical interventions. However, such a model requires a more detailed and bespoke clinical assessment than is typically conducted within the constraints of NHS wheelchair services. Furthermore, currently there is limited understanding of the different seating strategies which can be employed for each of the sources of spasticity and so it would again be a requirement to spend time trialling methods before a reliable framework, including relevant outcome measures, could be introduced into practice - and then the question remains as to whether we as an NHS service can standardise the use of these systems or components.

Although, I have detailed above my brief thoughts and some points for discussion, I am left with a couple of outstanding questions as to how this understanding can be implemented practically. Even if we could identify these subtypes of spasticity more precisely, could that lead to more tailored and effective seating interventions? Or is the complexity of doing so in a busy clinical environment too high for meaningful change?

Overall, the session not only expanded my understanding of spasticity but also challenged my assumptions about the role it plays in posture and mobility management. It has encouraged me to think more critically about how we assess and respond to spasticity presentations in clinic. Thanks to an increased awareness on the subject, as a service, we can begin building up a knowledge-base regarding the presentation of each spasticity mechanism, as well as the various strategies introduced, to determine what, if any, provides the best outcomes for our clients.

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