Poststroke spasticity affects an estimated 30% to 80% of stroke survivors—translating to approximately 1.8 to 5.6 million people in the US alone—yet many patients do not receive treatment until spasticity and secondary complications are well established, according to a recent statement from the American Heart Association.
Despite the availability of effective interventions, persistent gaps in recognition, referral pathways, and access to specialized care contribute to preventable disability. The cost of care is four times higher when spasticity is present.
The American Heart Association emphasizes earlier identification and management, with attention to the first 3 months after stroke as a key period for intervention. Spasticity may emerge within weeks after stroke and can interfere with voluntary movement, limit engagement in therapy, and exacerbate pain and fatigue during this critical recovery phase.
The statement reframes poststroke spasticity as involving multiple interacting components: abnormal muscle activation, impaired voluntary motor control, and structural tissue changes. As spasticity progresses, patients may experience pain, loss of joint flexibility, skin complications, and fixed contractures, all of which can undermine rehabilitation progress.
Evidence for Early Intervention
The statement reviews evidence supporting earlier use of interventions, with the strongest support for botulinum toxin (Level A evidence). Ten studies demonstrate that early botulinum toxin administration significantly reduces involuntary muscle activation in the short term, with some trials also reporting functional gains such as improvements on the Modified Barthel Index. Other interventions with probable benefit include task-specific training and functional electrical stimulation, though evidence for optimal timing and long-term outcomes remains limited.
Prevention Strategies
While randomized controlled trials on primary prevention are limited, observational evidence suggests that early mobilization within 24 to 72 hours after stroke, combined with comprehensive rehabilitation, may help preserve muscle length, reduce neural hyperexcitability, and maintain joint range of motion. Patients with severe motor weakness, early hyperreflexia, or lesions involving the internal capsule or brainstem are at highest risk and may benefit most from proactive strategies.
Improving Access and Recognition
The authors outline several system-level approaches to close care gaps: improving clinician education to increase awareness of early signs, establishing clearer assessment and referral pathways, and expanding the workforce trained in spasticity management. Currently, the ratio of Medicare beneficiaries to clinicians administering botulinum toxin exceeds 50,000:1, even in large metropolitan regions.
Current assessment relies primarily on the Modified Ashworth Scale, which measures resistance to passive movement but has limited ability to distinguish between reflex-mediated spasticity and structural muscle changes. The statement calls for validated screening approaches that can be used by nonspecialists in primary care and inpatient settings. The authors also highlight the potential role of telehealth and remote assessment tools, including wearable sensors, in extending access to specialized expertise.
The statement reframes poststroke spasticity as a potentially preventable and treatable complication rather than an inevitable consequence of stroke.
"Recognizing spasticity as a multidomain clinical syndrome—including involuntary muscle overactivity, impaired voluntary motor control, and passive tissue remodeling—offers important opportunities to improve timely diagnosis and treatment," notes author Sujani Bandela, MD, Vice Chair of UT Health San Antonio, The University of Texas at San Antonio, and colleagues.
The authors emphasize that addressing gaps in early recognition and intervention could substantially reduce the global burden of stroke-related disability while lowering long-term healthcare costs.
Full disclosures can be found in the statement.
Source: Stroke
