How OT and PT Manage the Muscle Overactivity That Follows Stroke, Spinal Cord Injury, Multiple Sclerosis, and Brain Injury

Spasticity is a velocity-dependent increase in muscle tone caused by damage to the pathways that control movement, and it is among the most common problems home health therapists encounter after stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, and cerebral palsy. It is more than tight muscles. Spasticity can pull an arm across the chest, curl a hand into a fist, point a foot downward, interfere with walking and dressing, make hygiene difficult, cause pain, and break down skin. It should be distinguished from contracture, which is a fixed shortening of soft tissue, and from rigidity, as seen in Parkinson’s disease, which is not velocity-dependent. Each calls for a slightly different approach.
Good management starts with assessment. Observe the limb at rest and during movement, in different positions, since tone varies with posture, fatigue, emotion, and time of day. The Modified Ashworth Scale is widely used, though its reliability is limited, so pair any score with functional observations: can the patient open the hand to wash it, put on a shirt, clear the foot during walking, or sit comfortably in the wheelchair? Ask about pain, spasms, and sleep. Document what the tone prevents the patient from doing, because function, not the number, is what guides treatment and justifies skilled care.
One clinical pearl is easy to miss: spasticity gets worse when something is wrong elsewhere. Noxious stimuli such as a urinary tract infection, a pressure injury, constipation, an ingrown toenail, a tight garment or catheter, or untreated pain can increase tone sharply. A sudden increase in spasticity is therefore a reason to look for a cause and call the nurse, not simply a reason to stretch harder. In patients with spinal cord injury at or above the mid-thoracic level, a new surge in spasms together with a pounding headache and sweating can signal autonomic dysreflexia, which is an emergency, as discussed in this series’ content on spinal cord injury.
Positioning is the foundation of care. A 24-hour approach to posture keeps limbs in positions that lengthen shortened muscles and protect joints: supported positioning in bed, a wheelchair cushion and back support that hold the pelvis and trunk well, footrests that keep the ankles at a good angle, and pillows or wedges that keep the arm supported rather than hanging. After stroke, protect the shoulder, which can subluxate when the arm is allowed to hang, and never pull on a weak arm during transfers or bed mobility. Teach family members and caregivers how to position and support the limb, because the hours between visits matter more than the hours during them.
Stretching and strengthening work together. Slow, sustained, low-load stretching is generally better tolerated than quick, forceful stretching, which can trigger a stronger spastic response. Evidence for stretching alone is modest, so combine it with active, task-specific practice. An older belief held that strengthening increases spasticity, but current evidence does not support it, and progressive strengthening and repetitive functional training improve movement without worsening tone. Constraint-induced approaches, task practice, and graded gait training build on the movement the patient does have. The aim is not a perfectly relaxed limb but a limb that can do more.
Splints and orthoses can help when used thoughtfully. Resting hand splints and ankle-foot orthoses may improve positioning and comfort, and an occupational therapist can fabricate or adjust them, set a wearing schedule, and teach donning and skin checks. The evidence that splinting alone prevents contracture is mixed, so splinting should complement stretching and positioning rather than replace them. Watch for redness, pressure marks, and skin breakdown, and stop and report if they appear. Serial casting and other procedures are medical decisions that the therapist supports by following the plan, monitoring skin and circulation, and reporting concerns.
The medical team has several tools, and therapists should understand their implications. Oral medicines such as baclofen, tizanidine, dantrolene, and diazepam can reduce tone but may cause sedation, dizziness, or weakness that raises fall risk, which should be reported. Abrupt interruption of baclofen, especially from an intrathecal pump, can cause severe rebound spasticity, fever, and confusion and is a medical emergency, so know whether a patient has a pump and when it is refilled. Botulinum toxin injections weaken overactive muscles for a few months, and the weeks after an injection, when the effect is at its peak, are an excellent time for stretching, strengthening, and task practice. Coordination between therapist and prescriber makes each treatment work better.
Caregiver training turns a plan into daily practice. Teach caregivers how to position the limb, perform a gentle sustained stretch, dress the affected side first, clean and dry a clenched hand or underarm, and transfer without pulling on a weak limb. Explain that forcing a limb against strong tone can cause pain and injury. Ask them to report new pain, redness, odor, skin breakdown, or a sudden change in tone. Medical social work helps with equipment funding, respite, and the emotional strain of caring for a family member whose body no longer follows commands.
Humane Care Therapy Inc. is therapist-owned and OT-operated, and our clinical leadership regards positioning, splinting, and functional task training as core skills in neurological home health. We supply licensed physical therapists, occupational therapists, speech-language pathologists, and medical social workers to home health agencies across Houston and Southeast Texas. Call (281) 619-3771, email info@humanecaretherapy.com, or visit humanecaretherapy.com.