Management of Poststroke Mobility and Spasticity

Stroke remains a substantial cause of adult disability, with about two-thirds of people who have had a stroke experiencing impaired mobility.¹ The greatest opportunity for recovery is within the first few months after a stroke, highlighting the importance of early and effective rehabilitation to ensure better functional outcomes and quality of life.¹ Age-standardized rates for stroke incidence, mortality, prevalence, and disability-adjusted life-years have all declined over the last decade, indicating progress in prevention and treatment.² Advances in acute stroke care and treatment have led to reduced disability. Timely emergency transportation to a hospital is also a major factor which contributes to sustained improvements and community reintegration for individuals who have experienced a stroke.³

Poststroke spasticity (PSS), a frequent complication impacting 17% to 43% of stroke survivors,⁴ is linked with pain, reduced function, and a decline in quality of life.⁵ The onset of spasticity varies, typically developing and peaking within 1 to 3 months after stroke.⁶

Five major guidelines for poststroke rehabilitation—Royal Dutch Society for Physical Therapy guidelines (2014), American Heart Association/American Stroke Association guidelines (2016), Canadian Stroke Best Practice Recommendations (2019), American Physical Therapy Association guidelines (2020), and Rehabilitation of Mobility after Stroke (2015)—are widely recognized. These guidelines generally agree on the rehabilitation timeline, which includes an acute phase lasting ~1 week after stroke, a subacute phase extending up to 6 months (divided into early and late subphases), and a chronic phase beginning after 6 months.

Poststroke rehabilitation guidelines are evidence-based and consistent.¹ We outline a concise format that can be applied in clinical practice for poststroke mobility (Table) and spasticity (Figure).

Acute Phase

Initiating intensive physical activity immediately after a stroke in the acute phase may not be sustainable. Although a gradual, less intense training regimen may yield less immediate improvement, it tends to result in better outcomes 3 months poststroke.⁷ Therefore, within the first 24 hours mobilization should be approached with caution, even for people who appear to be in good condition, and exercise intensity should begin lightly during the initial days, gradually increasing to a moderate level of intensity. Particularly in the acute phase, it is important to follow clinical guidelines for exercise and mobilization strategies that are tailored to the recovery stages from both neurobiologic and cardiovascular perspectives. These include thoughtful consideration of factors contributing to acute circulatory compromise such as cardiac complications (eg, reduced systolic dysfunction and arrythmias) that can limit cerebral perfusion and impaired cerebral autoregulation with blood brain disruption in the first week poststroke.⁸

Subacute/Chronic Phase

People Who Are Unable to Walk Independently

For people who are unable to walk without assistance, engaging in intensive, repetitive mobility task training early after a stroke significantly enhances the likelihood of independent walking at 6 months.⁹ This method requires substantial physical effort from therapists, so machine-supported training programs, using either exoskeletons or end-effector devices, have been used to assist with this training for people with severe neurologic impairment.¹⁰

Improvements in gait, and transitioning from nonambulatory (Functional Ambulation Category 0 or 1) to independent walking (Functional Ambulation Category 4 or 5), have been observed only during the acute or early subacute phases. These improvements have not been achieved when intensive gait training was initiated during the late subacute or chronic phases after stroke among nonambulatory individuals.¹

People Who Can Walk Independently or With Minimal Assistance

For people who can walk independently or with minimal help, taking a high number of steps to increase physical activity is crucial for further improvement. However, the use of devices such as exoskeletons or end-effector systems does not offer additional performance benefits for this group.¹¹ The intensity of therapy should increase progressively over time, regardless of whether training involves a treadmill or other methods. This could include increasing walking speed, difficulty, or complexity and may also involve structured activity, such as with circuit training.¹²

Task-specific training combined with motor imagery, walking aids (eg, cane, stick), functional electric stimulation, and electroacupuncture are less-studied but may be incorporated into rehabilitation. The same applies to intensive, progressive training during the chronic phase after stroke.

For ambulatory individuals and those requiring minimal assistance, all guidelines recommend intensive, progressive, and task-oriented gait training to enhance walking abilities. Overground walking and treadmill-based therapies are recommended. Treadmill-based therapies are particularly useful for people with more severe impairments and can target specific aspects of walking (eg, speed, distance) while limiting the risk of falls in unfamiliar settings.¹ Emerging training methods, such as cognitive training, external stimulation, and virtual reality, have gained popularity in recent years. However, the evidence supporting the use of these methods is limited, and recommendations for these methods remain tentative.

Balance Training

Incorporating balance training within the context of standing and walking is crucial for achieving clinically meaningful improvements. A motor relearning program emphasizing activities of daily living (ADLs) significantly enhances functionally relevant balance measures, particularly during the subacute phase. There is evidence supporting the benefits of this program during the chronic phase, although this evidence is of lower quality.¹³ There is some evidence suggesting that increasing gait speed without simultaneous balance training may result in a higher incidence of falls. Thus, balance training tailored to specific contexts should be included in any mobility training program after stroke.¹⁴

Combining conventional gait training with mechanical device–assisted training (eg, treadmills, end-effector devices, exoskeletons) along with strength and endurance exercises can improve balance, especially in the subacute and chronic stages. In addition, study results demonstrated that Ai Chi (Tai Chi practiced in water) improved balance and muscle strength.¹⁵

Walking Velocity

Intensive training during the chronic phase after stroke can lead to increased walking velocity, although the overall quality of evidence supporting this is lower compared with the subacute phase.¹⁴ Goal-oriented, progressive gait velocity training with either a walking aid or minimal assistance should be implemented to enhance walking speed in people who can walk independently. In the subacute phase, synchronizing the stimulation of flexor reflex afferents with steps has been shown to boost walking speed.¹⁶

If this approach is not feasible, intensive gait training with or without a treadmill, an intensive supervised home training program, or training that incorporates flexor reflex afferent stimulation should be pursued during the subacute phase.¹⁴

In the chronic phase, suitable candidates should be provided with an orthosis with or without electric stimulation, if available.¹⁷

Walking Distance

To improve walking distance in people who can walk independently with or without aid or with minimal assistance, task-specific and goal-oriented endurance training should be prioritized, particularly during the subacute phase after a stroke.¹⁸ Otherwise, intensive gait training with or without the use of a treadmill or an intensive supervised home training program should be undertaken during the subacute stage.¹⁴

During the chronic phase, task-specific endurance training such as progressive aerobic treadmill exercises should be implemented. Alternatively, an orthosis with electric peroneal stimulation may be applied if indicated and available.¹⁹

Upper Limb Motor Rehabilitation

A variety of therapies are available for the rehabilitation of the upper limb following a stroke, each aimed at enhancing motor recovery and functional abilities. Notable among these are functional electrical stimulation (FES), noninvasive brain stimulation (NIBS) techniques (eg, transcranial direct current stimulation [t-DCS], transcranial magnetic stimulation [t-MS]), invasive methods (eg, epidural cortical stimulation, telerehabilitation, robot-assisted therapy), and strategies promoting cerebral plasticity.

FES is frequently utilized within the initial stages of rehabilitation for hemiplegic patients experiencing upper limb disabilities, typically 2 to 6 months following the onset of the stroke. In many cases, FES is applied in conjunction with other therapeutic modalities, including task-oriented exercises, exercise-based approaches, and occupational therapy sessions. This method has proven to be an effective rehabilitation strategy, whether used alone or in combination with other therapies, providing enhanced outcomes compared to traditional stroke management practices.²⁰

In addition, NIBS techniques such as t-DCS and t-MS have demonstrated the capability to significantly modify cortical excitability, resulting in improved motor functions in the affected limb. The modulation of cortical activity through these noninvasive methods can improve recovery.²⁰

Virtual reality (VR) therapy has emerged as a contemporary poststroke rehabilitation tool. This innovative approach immerses patients in an interactive virtual gaming environment, promoting engagement and facilitating the rehabilitation of impaired limbs.²⁰ Despite its potential benefits, further research is needed before broader clinical application of VR therapy in rehabilitation settings.

Vagus Nerve Stimulation (VNS) can also be used to improve upper limb function. As a form of neuromodulation, VNS can strengthen neural connectivity. It has been approved by the Food and Drug Administration for stroke survivors with moderate to severe arm and hand impairment among those who have already undergone standard treatments without further benefit.²¹

Brain-Computer Interface

Brain-computer interfaces (BCIs) are being studied extensively for clinical use in patients with communication and motor function challenges caused by conditions such as amyotrophic lateral sclerosis (ALS), stroke, and spinal cord injuries (SCI).²² These devices enable individuals with limited muscle control to communicate by using neural signals to operate alphanumeric grids, cursors, and web browsing tools.

When combined with traditional therapies, BCIs can improve poststroke rehabilitation by aiding in the recovery of motor functions and enhancing cognitive and emotional well-being.²² The integration of BCIs with technologies such as functional electrical stimulation (FES), virtual reality (VR), and robotic devices has led to notable improvements in motor skills, communication, and cognition for stroke survivors.²²

BCI rehabilitation includes assistive approaches for permanent disabilities and rehabilitative methods aimed at restoring brain functions through neuroplasticity. Despite the potential benefits of BCI rehabilitation, challenges regarding the technical aspects, usability, and cost of BCIs still need to be addressed.

Managing Spasticity Affecting Mobility Training in the Subacute and Chronic Phases

PSS is characterized by a velocity-dependent increase in muscle tone across 2 or more joints, along with severe paresis and functional loss, leading to significant disability and difficulty with ADLs. Brain lesions involving the basal ganglia, thalamus, insula, and specific white matter tracts—particularly the internal capsule, corona radiata, external capsule, and superior longitudinal fasciculus—are predictive of PSS, especially when these lesions compromise the corticospinal tract.^23,24

The importance of managing spasticity is increasingly recognized, as spasticity can limit limb movement and overall mobility while leading to secondary complications such as joint contractures and pain. These issues can exacerbate motor weakness and functional limitations and lead to reduced quality of life.^24a

Spasticity assessment typically involves a combination of quantitative and qualitative methods. The Ashworth Scale, the Modified Ashworth Scale, and the Tardieu Scale are commonly used in clinical settings.^24b A recent meta-analysis showed satisfactory interrater and intrarater reliability for the Modified Ashworth Scale, particularly when assessing the upper extremities.²⁵ The Spasticity-Associated Arm Pain Scale has been developed to evaluate pain linked to arm spasticity in adults with poststroke upper limb spasticity.²⁶

Active patient involvement through the Goal Attainment Scaling method, which measures how well a patient’s goals are achieved during intervention, can improve functional outcomes. Study results demonstrated improved goal attainment in people who participated in goal planning.²⁷

Oral Medications

Several oral medications with different mechanisms of action are used to treat poststroke spasticity including baclofen, tizanidine, dantrolene, and benzodiazepines. These medications provide marginal relief for focal spasticity and exhibit varying effects on segmental and generalized spasticity.⁴ They can also lead to dose-dependent adverse effects. The selection and combination of medications should be customized to the individual patient, with careful titration and close monitoring of both therapeutic benefits and side effects.

Botulinum Toxin Type A

Botulinum toxin type A (BoNT-A) injections may enhance active function in some people with arm spasticity.²⁸ BoNT-A therapy should be considered for clinically significant upper limb PSS that does not respond adequately to nonpharmacologic treatments, particularly when the goal is to support passive functions, such as preventing contractures or aiding in hygiene, washing, and dressing.

For the lower limbs, a systematic review demonstrated that BoNT-A reduced clonus activity in people with chronic ankle flexion spasticity. Velocity-dependent increase in muscle tone, a positive sign of upper motor neuron syndrome, can also be improved with BoNT-A therapy.²⁹

Neurolysis

A recent retrospective chart review of 93 individuals who underwent phenol neurolysis procedures showed a relatively favorable safety profile for this procedure. Adverse events associated with phenol neurolysis included pain (4.0%), swelling and inflammation (2.7%), dysesthesia (0.7%), and hypotension (0.7%).³⁰

Phenol and alcohol neurolysis can be considered for clinically significant PSS that does not respond adequately to nonpharmacologic treatments or oral medications, particularly when BoNT-A therapy is not an option.

Intrathecal Baclofen Therapy

Intrathecal baclofen therapy (ITB) has been shown to be effective in managing poststroke spastic hypertonia. A recent expert consensus panel recommended considering ITB early to prevent or delay complications associated with spasticity and to reduce subsequent functional impairments. The panel also noted that ITB should be reserved for cases where other treatments have failed.³¹

A randomized, controlled, open-label, multicenter trial demonstrated that ITB therapy is superior to conventional medical management with oral spasmolytics in terms of efficacy and pain control. Although more adverse events were reported by participants receiving ITB compared with those receiving conventional medical management, no new safety concerns were identified.³²

ITB treatment should be tested, initiated, adjusted, and monitored by physicians who have long-term management experience with this treatment option.

Surgical Management

Orthopedic surgery may be beneficial for correcting spastic hand or foot postures, improving active wrist and foot extension, enhancing residual function, and preventing complications such as contractures resulting from spastic posturing.³³

In select cases, after a thorough evaluation by a multidisciplinary team and exhausting other reversible treatment options for spastic movement disorders, surgical interventions that are tailored to the individual may be considered for chronic spastic movement disorders after stroke.

Conclusion

Management of poststroke mobility and spasticity must be tailored to the individual’s activity level and ability. Initiating the rehabilitation process soon after the stroke and continuing it well into the chronic poststroke phase with routine interim assessments to tailor therapy is ideal to ensure the most favorable health outcomes.