Quick Answer
Spasticity is velocity-dependent muscle overactivity caused by loss of brain inhibition after stroke. It affects roughly 20-40% of survivors within the first year (Wissel, J Rehabil Med 2013). Stretching alone does not resolve it. The evidence-based combination is: daily positioning and prolonged stretch, botulinum toxin injection for focal spasticity, ESWT or electrical stimulation as adjuncts, and — most importantly — continued active task training of the affected limb.
1. How families first notice it
The typical sequence: the arm was floppy after the stroke, then around week 3 it starts to bend at the elbow and the fingers close. Dressing becomes hard. Washing the palm becomes hard. At night the leg pushes into a pointed-toe position. These are all signs of increasing tone, not of the patient "getting stronger".
- Elbow bends and the fist clenches at rest
- Resistance felt when a limb is moved quickly, less when moved slowly
- Difficulty opening the hand for hygiene; skin breakdown or odour in the palm
- Ankle pushes into plantar flexion, causing toe-catching when walking
- Sudden jerks or clonus, especially at the ankle
2. Why stiffness happens
The stroke removes descending inhibition from the spinal reflex circuits. Stretch reflexes become hyper-excitable, so the muscle contracts against passive movement. Over weeks, the shortened muscle also loses sarcomeres and gains connective tissue — the biomechanical change that turns reversible spasticity into a fixed contracture.
3. The window that matters
Contracture develops fastest between month 1 and month 6. This is the same window in which neuroplastic recovery is strongest, which is why passive management alone is a poor strategy — the limb needs both anti-spasticity treatment and active use.
- Week 2-6: tone begins to rise; start positioning, splinting, daily prolonged stretch
- Week 6-12: consider botulinum toxin for focal spasticity limiting function or hygiene
- Month 3-6: combine injections with intensive task training to convert range into function
- Beyond 6 months: fixed contracture may require serial casting or surgical review
4. What works, ranked by evidence
Practical treatment stack used in stroke-specialist rehabilitation:
- Botulinum toxin type A for focal upper- and lower-limb spasticity — strongest evidence for tone reduction (Simpson, Neurology 2016)
- Prolonged positioning and stretch (30+ minutes) rather than short repeated stretches
- Extracorporeal shockwave therapy (ESWT) as an adjunct that reduces tone for weeks (Guo, Front Neurol 2017)
- Functional electrical stimulation of the antagonist muscle to restore reciprocal control
- Task-specific active training — the only element that converts reduced tone into real function
- Oral antispastic medication only when spasticity is generalised, due to sedation and weakness
5. What does not work on its own
Two-minute stretches at the end of a session, massage alone, heat alone, or resting the limb "so it does not get worse". Immobilisation is the single fastest route to contracture. The stiff limb must keep moving through range every day.
6. The Sanpiti approach
Sanpiti is a stroke-only, hospital-based inpatient rehabilitation service. A PM&R physician reviews tone every 2 weeks using the Modified Ashworth Scale, coordinates botulinum toxin timing, and sequences ESWT, PMS and TMS around the daily 2-3 therapy sessions so the reduced tone is immediately used in task training rather than lost.
Frequently Asked Questions
Is spasticity a sign that recovery is starting?
Not exactly. Returning tone often appears at the same time as returning voluntary movement, but spasticity itself is not recovery. It needs to be managed so that emerging movement can be used.
How soon after stroke can botulinum toxin be given?
It is commonly used from around 6-12 weeks when focal spasticity limits function, hygiene, or positioning. The decision is made by a physician, and results last approximately 3-4 months, which is why it is paired with intensive therapy during that period.
Can spasticity be cured permanently?
Spasticity can usually be controlled to a level that does not limit function, but the underlying brain injury remains. Long-term control depends on continued daily range of motion and active use of the limb.
What is the difference between spasticity and contracture?
Spasticity is an active, reflex-driven resistance that varies with speed and effort. Contracture is a fixed shortening of muscle and connective tissue that does not release even under anaesthesia. Spasticity is treatable; contracture is largely preventable but poorly reversible.
Talk to a PM&R physician about stiffness
Early tone assessment prevents fixed contracture. Sanpiti reviews spasticity every 2 weeks and sequences treatment with daily intensive therapy.