- Spasticity and contractures may be managed by antispastic pattern positioning, range-of-motion exercises, and/or stretching [Evidence Level: Early-Level C; Late-Level B].
- Chemo-denervation using botulinum toxin can be used to reduce spasticity, increase range of motion, and improve gait, for patients with focal symptomatically distressing spasticity [Evidence Level: Early – Level C; Late-Level A].
Spasticity, defined as a velocity dependent increase of tonic stretch reflexes (muscle tone) with exaggerated tendon jerks can be painful, interfere with functional recovery and hinder rehabilitation efforts. If not managed appropriately, stroke survivors may experience a loss of range of motion at involved joints of the ankle and foot, which can cause difficulties with ambulation.
To achieve timely and appropriate assessment and management of lower limb spasticity the organization requires:
- Extent of change in functional status scores using a standardized assessment tool (e.g., FIM® Instrument) from admission to an inpatient rehabilitation program to discharge (average and median).
- Extent of change in lower limb functional status using a standardized assessment tool (e.g., Chedoke-McMaster Stroke Assessment sub scale) from admission to an inpatient rehabilitation program to discharge.
- Extent of change in lower limb spasticity scores using a standardized assessment tool (e.g., Modified Ashworth Scale) from admission to an inpatient rehabilitation program to discharge.
- Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
- Median length of time spent in active rehabilitation on a stroke rehabilitation unit during inpatient rehabilitation.
- Median total length of time spent on a stroke rehabilitation unit during inpatient rehabilitation.
- Ensure consistency in start time for all time-based measures, and document the definition of start and stop times for transparency and replication.
Health Care Provider Information
- Table 1: Stroke Rehabilitation Screening and Assessment Tools
- FIM® Instrument
- AlphaFIM® Instrument
- hedoke-McMaster Stroke Assessment
- Modified Ashworth Scale
- Stroke Engine
Information for People with Stroke, their Families and Caregivers
- Taking charge of your stroke recovery: Rehabilitation and recovery infographic
- Taking charge of your stroke recovery: Transitions and community participation infographic
- Aphasia Institute
- Post Stroke Checklist
- Stroke Resources Directory
- Your Stroke Journey
- Stroke Engine
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. Kluding et al. (2008) reported that eight 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 Botulinum toxin–type A (BTX-A) for treatment of lower-limb spasticity is not as well-studied compared with the upper extremity. A meta-analysis (Foley et al. 2010), which included the results from 8 studies reported a moderate increase in gait speed associated with BTX-A (SMD= 0.193±0.081, 95% CI 0.033 to 0.353, p<0.018). Kaji et al. (2010) randomized 120 patients with lower limb spasticity following a stroke of greater than six months post onset to receive a single treatment of 300 U Botox® or placebo. There was a significantly greater reduction in mean modified Ashworth Scale 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. (2003) 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, eight and 12 weeks following treatment. Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity at week four only.
Intrathecal baclofen is popular treatment for spasticity in many populations including stroke, spinal cord injury, and cerebral palsy. Meythalar et al. (2002) performed a cross-over randomized controlled trial among individuals with chronic stroke. At one year the authors noted that spasticity had improved, as evidenced by a decline in Ashworth scores and reflex scores (p<0.01 for both); spasm frequency scores did not improve (p>0.05).