3. Range of Motion and Post-Stroke Spasticity

Note

Spasticity is a common consequence of stroke and can negatively affect function, range of motion, pain, skin integrity, care needs, and engagement in rehabilitation. Routine assessment is essential to identify and manage these potential impacts effectively.

Recommendations and/or Clinical Considerations

Section 3.0 Clinical Considerations for Assessment of Post-Stroke Spasticity

Spasticity assessment should be a component of neurological assessments for an individual with stroke. Refer to Section 2 on Shoulder Pain for additional information.
Assessment for spasticity and its potential complications should be conducted regularly, throughout the continuum of stroke care, to ensure timely identification and management.
Assessment and management of complicated post-stroke spasticity should be carried out by a healthcare professional with expertise in spasticity management and an interprofessional team with specialized expertise in spasticity care whenever possible and using validated assessment and outcome measures.
Assessment of spasticity should include identification and consideration of factors that can increase post-stroke spasticity (e.g., noxious stimuli such as infections, pain or constipation).

3.1 Upper Extremity

Static stretching with positioning orthoses may be considered to treat wrist-flexor spasticity [Conditional recommendation; Moderate quality of evidence].
1. Routine use of splints alone for spasticity is not recommended [Strong recommendation; High quality of evidence].
2. The use of splints may be considered to prevent complications of spasticity on an individualized basis. If a splint is used, a plan for monitoring the splint for effectiveness should be followed [Strong Recommendation; Low quality of evidence].
Chemo-denervation using botulinum toxin should be considered to increase passive range of motion for patients with spasticity of the shoulder [Early: Strong recommendation; Moderate quality of evidence; Late: Strong recommendation; High quality of evidence].
Chemo-denervation using botulinum toxin should be considered over oral medications as first-line treatment of focal spasticity. [Strong recommendation; High quality of evidence].

Section 3.1 Clinical Considerations

Oral medications (i.e., tizanidine and baclofen) can be considered as an adjunct for the treatment of disabling spasticity, but side effects of fatigue and drowsiness are common.
Adjunct treatments (i.e., electrical stimulation, CIMT, taping, dynamic splinting, extracorporeal shock wave therapy), in addition to chemo-denervation using botulinum toxin may be considered to treat spasticity.
Non-invasive brain stimulation may be considered in the treatment of spasticity. Note these interventions are not yet available/approved for use in Canada.
Follow-up assessments for spasticity should be included as part of the routine care plan during inpatient rehabilitation, and at the start and end of outpatient rehabilitation therapy.

3.2 Lower Extremity

Active stretching and joint mobilization exercises is recommended in both the early and late stages to increase ankle joint range of motion and gait parameters, and to decrease spasticity [Strong recommendation; Moderate quality of evidence].
Chemo-denervation using botulinum toxin is recommended to reduce focal spasticity in individuals with stroke [Strong recommendation; High quality of evidence].
Intrathecal baclofen may be considered for cases of severe, chronic, and intractable spasticity that cannot be effectively managed with oral antispasmodic agents [Strong recommendation; Low quality of evidence].

Section 3.2 Clinical Considerations

Oral medications (i.e., tizanidine and baclofen) can be considered as an adjunct for the treatment of disabling spasticity, but side effects of fatigue and drowsiness are common.
Whole body vibration may be considered to decrease lower extremity spasticity in the early stage, but not in the late stage.
Extracorporeal shock wave therapy (ESWT) should be considered to decrease spasticity and pain associated with plantar flexor spasticity.

Rationale +-

Post-stroke spasticity is characterized by increased muscle tone and abnormal reflexes, which can significantly impact both upper and lower extremity function. When the upper extremity is affected, the ability to perform personal care tasks such as dressing, and eating, is reduced, which may lead to dependence on caregivers or family members. Individuals with lower extremity spasticity have difficulty standing, walking and maintaining balance. Management and treatment of post-stroke spasticity can facilitate the rehab process by decreasing the burden of care and improving comfort and engagement in activities.

While post-stroke spasticity can interfere with rehabilitation and lead to negative consequences, it may also offer functional benefits in certain cases—for example, increased finger flexor spasticity may aid grip, or knee extensor spasticity may assist with weight bearing. Assessing the functional impact of spasticity and clearly identifying treatment goals are essential components of effective spasticity management.

Individuals with stroke emphasize the importance of education on spasticity management for individuals with stroke, their family and caregivers and note that certain strategies may be helpful to provide relief and management. They emphasize the impact spasticity can have on ability to engage in exercise and ADL. Accordingly, strategies to manage spasticity should be discussed with individuals with stroke using a person-centred approach.

Performance Measures +-

System Indicators

Availability of expertise and programs in post-stroke spasticity.
Proportion of individuals with stroke who experience post-stroke spasticity.

Process Indicators

Time from stroke onset to first functional assessment including signs of spasticity.
Frequency and intensity of therapy for post-stroke spasticity.
Access to specialized services to support management of post-stroke spasticity.

Patient-Oriented Indicators

Change (improvement) in functional status scores using a standardized assessment tool following therapy for post-stroke spasticity – measures at 90 day, 6 months and one year following stroke.
Extent of change in upper and lower limb spasticity scores using a standardized assessment tool (e.g., Modified Ashworth Scale) from admission to an inpatient rehabilitation program to discharge.
Change in reported pain levels, based on validated pain rating scale measures from baseline to defined measurement periods (e.g., 30, 60, 90 days following stroke).
Changes in quality of life measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke).
Levels of burden of care on family and caregivers supporting an individual with post-stroke spasticity.

Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery and Community Participation following Stroke, Part One: Stroke Rehabilitation Planning for Optimal Care Delivery module; and, Part Three: Optimizing Activity and Community Participation following Stroke, Update 2025
Heart & Stroke: Taking Action for Optimal Community and Long-Term Stroke Care: A resource for healthcare providers
Stroke Engine: FIM® Instrument
UDS: AlphaFIM® Instrument
Stroke Engine: Modified Ashworth Scale
UF Health: Pain scales
Stroke Engine

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List 3a

Evidence Table and Reference List 3b

Upper extremity spasticity

Spasticity can be painful, interfere with functional recovery and hinder rehabilitation efforts. If not managed appropriately, patients may experience a loss of range of motion at involved joints of the arms, which can result in contracture. Although it is a common in clinical practice to use range-of-motion or stretching exercises and splints to prevent or treat spasticity or contracture following stroke, there is a lack of evidence supporting their benefit. Harvey et al. ⁸² included the results of 49 RCTs in a Cochrane review including participants with neurological condition, advanced age, those with a history of trauma and those with underlying joint or muscle pathology. Of these, 11 trials included stroke cohorts treated for upper extremity impairment. Trials evaluated the effect of stretching programs (casting, splinting, self-administered, positioning, and sustained passive stretch) on preventing contractures. Stretching programs did not significantly increase joint mobility, improve spasticity, activity limitations, or pain either after the intervention or at follow-up, when compared with usual care. Salazar et al. ⁸³ included the results from three RCTs of patients post stroke with upper extremity spasticity and reported that static stretching with positioning orthoses was associated with significantly greater reduction in wrist-flexor spasticity compared with no therapy or conventional physiotherapy (mean difference [MD]= -1.89, 95% CI -2.44 to -1.34).

While it is well-established that treatment with Botulinum toxin–type A (BTX-A) reduces focal spasticity in the finger, wrist and elbow, it remains uncertain whether there is also improvement in upper extremity function. In the BOTOX® Economic Spasticity Trial (BEST), 273 persons with chronic post-stroke upper and lower extremity spasticity were randomized to receive a single dose of BTX-A with an optional second dose offered ≥ 12 weeks after the first injection, or placebo in addition to usual care. Dosing and site of injection was based on clinician judgement. In the publication of the trial that was dedicated to functional outcomes, ⁸⁴ there were no significant differences between groups at weeks 12, 24 or 52 with respect to the percentage of patients who achieved their principal active functional goal (33.1% vs. 28.9%, 40.9% vs. 33.3% and 45.0% vs. 52.4%, respectively), although a higher number of persons in the BTX-A groups achieved their secondary passive functional goals at 24 weeks, (60.6% vs. 38.6%, p=0.016), but not at weeks 12 or 52. In another BEST publication, BTX-A was more effective than placebo in reducing pain from baseline to week 12. ⁸⁵ Higher proportions of patients with pain in the BTX-A group achieved ≥30% and ≥50% reductions in pain. Shaw et al. ⁸⁶ randomized 333 subjects < 1 month following stroke with spasticity of the elbow (modified Ashworth Score [MAS] >2) and/or spasticity of the shoulder, wrist or hand with reduced arm function to receive 100 or 200 U Dysport ® in addition to a standardized therapy program provided for one hour/day, 2x/week for 4 weeks) or therapy program only. Repeat injections were available to participants in the intervention group at 3, 6 and 9 months. There was no significant difference in the percentage of patients who had achieved a successful outcome (defined by 3 different levels of improvement on the Action Research Arm Test, depending on baseline arm function) at one month following treatment: 25% of patients in the treatment group compared with 19.5% of patients in the control group (p=0.232). However, significant differences in favor of the intervention group were seen in muscle tone at 1 month; upper extremity strength at 3 months; basic arm functional tasks (hand hygiene, facilitation of dressing) at 1, 3, and 12 months, and pain at 12 months. McCrory et al. ⁸⁷ reported there were no significant between group differences in Assessment of Quality-of-Life scale change scores, pain, mood, disability or carer burden at 20 weeks in 102 patients with moderate to severe spasticity of the arm, who received 750-1,000 U Dysport ® or placebo an average of 6 years following stroke. In a systematic review, Sun et al. ⁸⁸ pooled the results from 18 RCTs of adults with upper extremity spasticity following stroke in which a wide variety of outcomes were reported. Trials compared one-time injections of BTX-A formulation with placebo. At 4 to 16 weeks, treatment with BTX-A was associated with significant improvement in muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55), physician global assessment ([SMD=0.51; 95% CI 0.35-0.67) and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20), with no significant improvement on active upper extremity function (SMD=0.49; 95% CI -0.08 to 1.07). BTX-A may also be used in addition with other treatment modalities to reduce spasticity. Other treatments include electrical stimulation, ^{89, 90} constraint-induced movement therapy,⁹¹ taping, ⁹² and dynamic splinting. ⁹³

In cases where spasticity is generalized, and it would be impractical, or contrary to patients’ wishes to inject multiple muscle groups with BTX-A, the use of oral agents may be considered as an alternative treatment. Traditional pharmacotherapies for spasticity include centrally acting depressants (baclofen and tizanidine) and muscle relaxants; (dantrolene) however; these treatments are only partially effective in treating spasticity and have the negative side effects of weakness and sedation. Treatment with oral baclofen has not been well studied in the stroke population and is used more frequently in patients recovering from spinal cord injury; however, in one small RCT, Güntürk et al. ⁹⁴ reported that in patents randomized to receive treatment with BTX-A (total dose 100-300 U) or oral baclofen (total dose 3-80 mg daily), median elbow, wrist and finger MAS scores and pain scores had improved significantly at 6 weeks in both groups, with no significant differences between groups. There was no significant improvement in median Barthel Index scores within, or between groups at 6 weeks. Tizanidine has been well-studied in other conditions including multiple sclerosis and acquired brain injury and has a better side effect profile than other oral agents. There is only a single open-label trial of the use of tizanidine post stroke. ⁹⁵ Following 16 weeks of treatment in which 47 patients received a maximum daily dose of 36 mg (mean 20 mg), there was a decrease in mean combined total MAS scores (9.3 vs. 6.5, p=0.038). There were also significant improvements in pain, quality of life, and physician assessment of disability.

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment that uses acoustic shock waves to reduce pain and heal tissue and has been used traditionally to treat injuries such as tendonitis, and other soft tissue injuries, but has also been used for the treatment of spasticity following stroke. Cabanas-Valdés et al. ⁹⁶ included the results of 16 RCTs, including 764 participants who had sustained an ischemic or hemorrhagic stroke and had residual upper-extremity hemiparesis and spasticity. In most trials, ESWT plus conventional therapy was compared with conventional therapy only. A sham condition was used in two trials. ESWT was associated with a significant reduction in MAS and pain scores compared with therapy alone, and an improvement in Fugl-Meyer Assessment scores.

Non-invasive brain stimulation using either transcranial direct-current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) has been shown to be beneficial for the treatment of upper-extremity spasticity. rTMS and tDSC were associated with significant reductions in mean MAS scores compared with the control condition (sham stimulation, +/- cointerventions) in a systematic review authored by Wang et al ⁹⁷ (MD= −0.40, 95% CI −0.56 to −0.25 and MD=−0.65, 95% CI −1.07 to −0.22, respectfully), including the results of 14 RCTs of 236 patients with upper extremity spasticity.

Lower Extremity Spasticity

Few studies have been published examining the prevention or treatment of spasticity or contracture using antispastic pattern positioning, range of motion exercises, stretching and/or splinting in the lower extremity. Chen et al. ⁹⁸ randomized 121 patients discharged from inpatient rehabilitation, an average of 3.3 months post stroke, with lower extremity spasticity to a nurse-guided home-based rehabilitation exercise program, aimed at reducing spasticity and improving mobility, which lasted for 12 months, or to receive conventional rehabilitation. At the end of 12 months, there was significantly greater improvement in mean lower extremity MAS scores, as well as motor function, gait speed and BI scores in the home-based rehabilitation exercise program group (from 3.32 to 1.07 vs. 3.27 to 1.69, p for group x time interaction =0.004). Kluding et al. ⁹⁹ reported that 8 sessions of functional task practice combined with ankle joint mobilizations, provided over four weeks, resulted in increased ankle range of motion, compared with a group that received therapy only, in the chronic stage of stroke. The participants in the intervention group gained 5.7 degrees in passive ankle range of motion compared with 0.2 degrees in the control group (p<0.01).

The use of BTX-A for treatment of lower extremity spasticity is not as well-studied compared with the upper extremity. In the REFLEX Study, Wein et al. ¹⁰⁰, included 468 patients, recruited from 60 centres in the United States with spasticity of the ankle (MAS ≥3) following stroke of duration >3 months. Participants were randomized to receive either BTX-A (Botox® 300–400 U) or placebo and followed for 12 weeks during the double-blind phase of the trial. During this phase of the trial there was significantly greater improvement in mean MAS ankle scores from baseline to 4-6 weeks in the BTX-A group (-0.81 vs. -0.61, Δ= -0.20). During the open-label phase of the trial, mean MAS scores were reduced by -1.2 points for patients in the BTX-A group and by -1.4 points for those in the group that initially received placebo. During the double-blind phase, the mean Physician-assessed Clinical Global Impression of Change (CGI) from baseline to 4-6 weeks was significantly greater in the BTX-A group (0.86 vs. 0.65; Δ=0.22). At the end of the open-label phase, patients in both groups had improved to an average of 1.6 points. Goal Attainment Scale (GAS) scores, reflecting individualized patient goals, showed incremental improvements with each subsequent treatment cycle.

A systematic review by Doan et al. v101 included the results of 12 RCTs of patients with lower extremity spasticity. Duration of stroke was greater than three months in 8 trials. Patients were randomized to receive BTX-A injections or placebo. At four weeks, there was significantly greater improvement in measures of spasticity (Ashworth Scale [AS], MAS) in the BTX-A group (SMD=-0.61, 95% CI -0.92 to -0.3). Kaji et al. ¹⁰² randomized 120 patients with lower extremity spasticity following a stroke of greater than 6 months post onset to receive a single treatment of 300 U Botox® or placebo. There was a significantly greater reduction in mean MAS scores at weeks four, 6 and 8 in the treatment group compared with the control group; however, there were no significant differences between groups at week 10 or 12. Pittock et al. v103 compared escalating doses of BTX-A with placebo and found that the highest dose (1,500 U Dysport ®) was associated with the greatest relief of calf spasticity compared with placebo at four, 8 and 12 weeks following treatment. Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity by week four only.

Intrathecal baclofen (ITB) is not generally used in the treatment of post-stroke spasticity, but can be considered in certain cases, particularly if other treatment options are ineffective or if the spasticity is severe and disabling. It is used more commonly in spinal cord injury, multiple sclerosis and cerebral palsy. The Spasticity In Stroke–Randomized Study’ (SISTERS) ¹⁰⁴ included 60 patients recruited from 11 rehabilitation centres in Europe and the US with chronic stroke with spasticity in ≥2 extremities and an AS score ≥3 in at least two affected muscle groups in the lower extremities. After a run-in period, patients were randomized to receive ITB or conventional medical management, using a combination of oral antispastic medications, comprising at least one of oral baclofen, tizanidine, diazepam (or other benzodiazepines), or dantrolene. At 6 months post treatment, the mean reduction in lower extremity AS scores was significantly greater in the ITB group (-0.99 vs. -0.43, p=0.0140).

Less conventional treatments for the treatment of lower extremity spasticity include extracorporeal shock wave therapy (ESWT) and whole-body vibration (WBV), although both are considered a complementary therapy, and are used in addition to traditional rehabilitation therapies. In two small RCTs, ESWT was associated with significantly greater reductions in spasticity compared with conventional therapy. ^{105, 106} In a systematic review including 11 RCTs, Zhang et al. ⁷⁶ reported that WBV was associated with a significant reduction in lower extremity spasticity (SMD= −0.26, 95% CI −0.44 to −0.07). Treatment was most effective in the acute/subacute stage of stroke and in patients under 60 years.

Sex & Gender Considerations