Spasticity After Stroke: Causes and Treatment
Spasticity is an increase in muscle tone that makes the muscles stiff and resistant to movement, especially when they are stretched quickly. It develops in a substantial proportion of patients in the weeks and months after a stroke, typically affecting the elbow, wrist and finger flexors and the calf muscles.
Why does spasticity occur?
Stroke damages the pathways that normally control reflexes in the spinal cord. Without this control, the stretch reflex becomes overactive. Spasticity is not always harmful: some patients use leg stiffness to support standing. Treatment is needed when it causes pain, limits function or care, or leads to contractures.
Further reading: the guide “Stroke” and the articles Stroke Rehabilitation: Ischaemic and Haemorrhagic Stroke and Shoulder Pain After Stroke: Causes and Treatment.
Treatment options
Treatment is planned individually after examination [3]:
- Stretching, positioning and splints to maintain muscle length
- Physiotherapy and task-oriented training to improve active control
- Botulinum toxin type A injections into selected muscles; meta-analyses show they reduce upper-limb spasticity [1, 2]. The effect is temporary and is combined with therapy.
- Oral medicines such as baclofen or tizanidine for more widespread spasticity, limited by side effects such as drowsiness
- Electrical stimulation and, in selected cases, surgical or intrathecal options
What spasticity is
Spasticity is a velocity-dependent increase in muscle tone (the muscle resists more strongly the faster it is stretched). After a stroke it often appears in the weeks or months after the event, typically in the elbow, wrist and finger flexors (the muscles that bend the joints) and in the calf muscles. It can be mild and barely noticeable, or strong enough to cause pain, a clenched hand, a turned-in foot or difficulty with washing and dressing.
Typical course
Muscle tone is often low (flaccid) immediately after a stroke and may increase over the following weeks. In many people spasticity peaks within the first months and then stabilises. Its severity can change from day to day: pain, a full bladder, constipation, skin irritation, infection, cold, fatigue and stress commonly make it worse. A sudden increase should therefore prompt a search for such a trigger.
How spasticity is assessed
Your physical medicine and rehabilitation (PM&R) specialist examines muscle tone at rest and during movement, joint range of motion, pain, posture and the effect on everyday tasks. Simple clinical scales, such as the Modified Ashworth Scale (a 0–4 score of resistance to passive stretch), help to follow changes over time. The key question is not only “how stiff is the muscle?” but “does the stiffness cause a problem, and what goal should treatment serve?” Some spasticity may even help, for example by supporting a weak leg during standing.
Treatment in general terms
Treatment is planned in steps and combined rather than used alone:
- Daily stretching and positioning to maintain joint range and prevent contractures (permanent shortening of muscles and tendons).
- Active, task-oriented exercise with your physical medicine and rehabilitation specialist and the physiotherapist, so that the limb is used in meaningful movements.
- Splints and orthoses (supportive braces), for example a resting hand splint or an ankle-foot orthosis.
- Oral medication in selected cases; side effects such as drowsiness need to be weighed.
- Botulinum toxin injections into specific overactive muscles, usually followed by targeted exercise and splinting to make use of the period of reduced tone.
- Rarely, other specialised procedures for severe, widespread spasticity.
After acute hospital care, the whole process is best led and advised by a PM&R physician, who sets goals and coordinates the therapy and support treatments.
What families can do at home
- Help with the stretching programme each day, slowly and without forcing a joint.
- Position the affected arm supported on a pillow and avoid pulling on the weak shoulder.
- Watch for triggers: constipation, urinary problems, pressure areas on the skin, tight footwear.
- Check splints for redness or pressure marks on the skin.
- Encourage use of the affected hand and leg in daily activities as advised.
When to consult your PM&R specialist
Seek review if stiffness is increasing, causes pain or skin problems, makes hygiene or dressing difficult, if the hand or foot is becoming fixed in one position, or if spasticity worsens suddenly. At home, consult a PM&R specialist who can guide the therapy and support treatments.
Frequently asked questions
Does spasticity mean recovery has stopped? No. Spasticity is a sign of changes in motor control, not an indicator that recovery is over.
How long does a botulinum toxin injection work? Usually several months. Its value depends on combining it with stretching and active therapy. See also Hemiplegia.
Can spasticity appear months after a stroke? Yes. It can develop gradually over weeks to months, so regular follow-up is useful even if the limb was initially floppy.
Should all spasticity be treated? Not necessarily. Treatment aims at specific goals such as less pain, easier care or better function; mild spasticity that causes no problem may only need monitoring.
Assessment and contact
You can request an appointment or a second-opinion review of existing reports and imaging: Contact & second opinion (WhatsApp). This page is general health information. Diagnosis and treatment decisions are made individually after examination.
Sources
- Dong Y, et al. Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury: a systematic review with meta-analysis and trial sequential analysis. Eur J Phys Rehabil Med. 2017. PMID: 27834471
- Jia S, et al. Botulinum Toxin Type A for Upper Limb Spasticity in Poststroke Patients: A Meta-analysis of Randomized Controlled Trials. J Stroke Cerebrovasc Dis. 2020. PMID: 32305277
- Winstein CJ, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016. PMID: 27145936