How Spasticity Treatment Works: Understanding Exercise, Botox, & Add-On Therapies

When muscles become stiff and rigid after a neurological injury like a stroke, it indicates a condition called spasticity. Treatment often involves exercise to help rewire the brain. However, when spasticity treatment exercises alone aren’t enough to produce results, other therapies such as Botox can be added to help relax the muscles.

You’re about to learn how spasticity treatment works, what exercises and therapies are available, and how you can maximize your chances of regaining mobility.

This guide has been updated to be even more comprehensive than before, so use the links below to jump straight to any section.

Table of contents:

• Causes
• Treatment
• Exercises
• Therapies
• Botox
• Medications
• Upper limb treatment
• Lower limb treatment
• Contractures
• Orthotics

What Causes Muscle Rigidity and Spasticity?

To understand what causes muscle rigidity and spasticity, let’s look at how your muscles typically function.

Under normal circumstances, your muscles and brain are in constant communication. Your muscles tell the brain how much tension they’re under, and your brain tells your muscles how and when to move. When a neurological injury such as a stroke damages the areas of the brain that control movement, it can impair the brain’s ability to communicate with the affected muscles.

As a result, your muscles may become “over-active” and remain in a state of involuntary contraction, formally known as spasticity. Spasticity is velocity-dependent, which means that the more rapidly a muscle is stretched, the more severely it will contract. However, spasticity can also be present at rest, as sometimes severe spasticity causes muscles to stay in a prolonged state of contraction.

Individuals with mild spasticity may experience muscle stiffness but can still move the muscle through its full range of motion. When spasticity is severe, however, muscles can become rigid and significantly affect mobility.

Furthermore, spasticity can affect any area of the body. Sometimes a person’s hand may become clenched in a fist, their arm may curl into their chest, or their toes may curl under. When spasticity is severe it can be painful and functionally limiting, making treatment even more important.

What Are the Goals of Spasticity Treatment?

There are generally two types of spasticity treatment: exercises that address the root issue causing spasticity and medications that address muscle tightness as a symptom. Both can play equally important roles in your recovery.

First, spasticity treatment exercises work by addressing damage to the nervous system. When exercises are repeated, it stimulates the brain and sparks neuroplasticity, which is the mechanism the brain uses to rewire itself.

Spasticity is caused by miscommunication between the brain and muscles; and spasticity treatment exercises directly improve this communication through neuroplasticity. When the brain and muscles can communicate with each other again, the brain can tell the affected muscles to relax and contract when appropriate.

Practicing spasticity treatment exercises on a daily basis can provide the brain with the stimulation it needs to rewire itself and promote adaptive changes. However, it can take some time for this rewiring to occur. This is where other spasticity treatments can help.

Certain medications like Botox and baclofen help address the symptom of spasticity. However, these drugs do not promote neuroplasticity. Instead, they temporarily relieve the symptom of muscle tightness.

Because the results are temporary, medications often work best when they are used to create a window of opportunity to complete daily rehabilitation exercises that focus on promoting neuroplasticity. That way, your short-term gains can make way for long-term results.

Spasticity Treatment Exercises

Spasticity treatment exercises are not designed to strengthen the muscles — at least, not primarily. Instead they are designed to activate neuroplasticity and improve the communication between your brain and muscles. Over time, this helps spasticity subside and allows your affected muscles to remain relaxed unless functionally contracting.

Because everyone experiences spasticity differently, a personalized approach to treatment is ideal. What works for some may not be as effective for others. Therefore, it is recommended to work with a team of rehabilitation specialists to optimize your recovery outcomes. Below, we’ll discuss some of the spasticity treatment exercises for stiff muscles after stroke:

Physical Therapy Exercises

Physical therapists specialize in stimulating the mind-body connection through exercise. Your PT can assess where spasticity is affecting your mobility and select helpful spasticity treatment exercises for you to practice.

Often, your PT works with you in the clinic, where they may use a combination of exercise, modalities, and manual therapy techniques. They will also recommend exercises for you to do on your own at home. These are essential to complete, as neuroplasticity is promoted through repetitious tasks. Completing home exercises increases how often the brain is stimulated to make adaptive changes.

For example, you can target spasticity in the hips with a seated marching exercise:

As you can see, this leg exercise is not designed to strengthen the muscles. Instead, it’s a therapeutic stretching movement that helps stimulate the brain when repeated on a regular basis.

Occupational Therapy Exercises

When spasticity affects your ability to accomplish everyday activities, that’s where an occupational therapist can help. Your OT will have you practice everyday activities to spark neuroplasticity, or they may teach you how to use adaptive tools to help you become more functional and independent after a stroke.

For example, you can target spasticity in the hand by practicing an everyday activity like pinching:

The ability to pinch and grasp objects is important for many of the activities of daily living such as getting dressed or brushing your teeth.

Passive Exercises

When spasticity is severe, or when post-stroke paralysis is involved, you may find it difficult to do active therapy exercises. This is where passive exercises come into play. By assisting your affected muscles through the movement, you can still activate neuroplasticity and encourage the brain to rewire itself. With enough repetition, you may regain some movement.

For example, you can target spasticity in the wrist by practicing a hand exercise passively.

In this exercise, you can use your non-affected hand to move your affected hand through the exercise. This passive movement helps stimulate the brain and encourages spasticity to subside over time.

Range of Motion Exercises

Regardless of the severity of your spasticity, it’s important to move your affected muscles safely through their range of motion multiple times a day. Stretching is important for preventing spasticity from getting worse, along with preventing other post-stroke complications like pressure sores (if you’re bedridden or use a wheelchair regularly). Never stretch to the point of pain.

Therapies to Supplement Spasticity Treatment Exercises

Now that you know the various types of spasticity treatment exercises, let’s discuss two therapies that you can use in conjunction with exercises to enhance your results.

Electrical Stimulation

Electrical stimulation is a type of therapy where electrical currents are applied to the affected muscles through pads that attach to the skin. These electrical currents help stimulate the affected muscles, and promote their communication with the brain even more. In fact, combining electrical stimulation with rehab exercise has been shown to create better results than just exercises alone.

Talk to your therapist to see if it’s a good fit for you and learn where to place the electrodes. Do not use electrical stimulation if you have a pacemaker.

Electro-acupuncture

Acupuncture is an alternative treatment that comes from Traditional Chinese Medicine. It involves placing thin needles into specific “acupoints” on the body. When appropriate, a practitioner can apply electrical stimulation to the needles after they are inserted (electro-acupuncture). Electro-acupuncture has been shown to help reduce spasticity when combined with exercise.

It’s important to note that both electrical stimulation and electro-acupuncture are more effective when combined with rehab exercise, which further illustrates the important of spasticity treatment exercises.

When Is Botox Appropriate for Spasticity?

If you struggle with severe spasticity, then you may have difficulty doing exercises because your muscles will be too stiff. To help loosen things up, talk to your doctor or therapist about Botox injections.

Botox is a nerve block that helps temporarily relieve spasticity. Although the effects will wear off after 3-6 months, you can use the short-term reduction in muscle tightness to practice daily spasticity treatment exercises.

This will address the root problem of disrupted communication between the brain and muscles and encourage long-term improvement.

Other Medications and Procedures for Spasticity

Muscle stiffness and spasticity can also be treated with medications like baclofen, which is a muscle relaxant. It acts on the spinal cord and nerves to improve muscle movement.

This medication can be taken orally, or you can get a pump surgically implanted that releases a continuous supply. It’s called an intrathecal baclofen pump, and you can talk to your doctor to see if it’s a good fit for you.

Side effects from these medications can be severe, which makes a strong case for using the short-term relief provided to practice spasticity treatment exercises for long-term improvements.

There is a surgical procedure for spasticity called a rhizotomy where the surgeon permanently cuts the nerve rootlets in the spinal cord that are sending abnormal signals to the muscles. It’s predominantly used for individuals with cerebral palsy.

The effects are less studied but generally positive for spasticity in  individuals with neurological injuries other than CP, such as stroke, traumatic brain injury, and spinal cord injury.

Surgery is permanent and should be carefully considered after other options have been exhausted. Now that you understand the various spasticity treatments available, let’s talk about how to apply them to upper limb and lower limb spasticity.

Upper Limb Spasticity Treatment

Sometimes spasticity affects the upper limb, including the hand, wrist, and arm. Fortunately, there are many spasticity treatments available.

In addition to rehabilitative therapies, Botox is approved by the FDA for upper-limb spasticity treatment. If you would like some relief, talk to your doctor about getting Botox injections for your affected muscles.

Be sure to use the temporary relief to practice daily spasticity treatment exercises at home. If you struggle with sticking to a home therapy program, you can use motivating equipment like Flint Rehab’s FitMi.

The FitMi takes 40 therapeutic rehab exercises and turns them into an interactive experience. You can target specific muscles groups like the arm and hand. Many individuals with spasticity have seen improvement by using FitMi on a daily basis.

Here’s what some survivors with spasticity said about FitMi:

“I had a stroke 19 months ago, and I have hemiplegia on the right side and both my leg and arm were flaccid. My right shoulder, arm, and hand are mostly limp, so when I read about FitMi I figured it could only help. When it arrived I got it all installed, and started with my right arm at five minutes. Since my right side is limp, I have to use my left arm to help, but it really seems to be improving. My severe spasticity fights all the way, but I can feel the improvements in my right upper body. I’ve reached level 74 on the right arm!”

–William Z.

“My Dad wasn’t too motivated to do any exercises at home until I bought FitMi for him. He loves music and looks like it distracts him from pain while exercising. We’ve been using FitMi for over a month and his right arm spasticity is almost gone, we exercise daily.”

-Liudmila A.

William demonstrates the power of passive exercise while Liudmila shares the power of daily practice. No matter how you get your spasticity treatments exercises done, consistency is the key.

Lower Limb: How to Reduce Spasticity in the Legs

When spasticity affects the legs, it can make it difficult to walk and put you at greater risk of falling. Therefore, exercising the legs is an essential step for lower limb spasticity treatment. A great way to do this is through physical therapy.

If you’re eager to add more to your regimen, talk to your doctor about Botox, which is also FDA-approved for lower limb spasticity. Also, there is evidence that electro-acupuncture can be an effective add-on to your spasticity treatment exercises. In a meta-analysis of over 1,425 patients with spasticity, electro-acupuncture was shown to help with both upper and lower limb spasticity.

But if you want to optimize your ability to reduce spasticity in the legs, the key is exercise. Do your best to gently stretch your legs multiple times a day, and practice rehab exercises for the legs.

If you can walk with a walker or cane, try to walk daily to get some task-specific exercise. If you can’t walk yet, then have your therapist or a trained caregiver help you exercise your legs passively. The FitMi also contains exercises that target the legs and feet for a structured approach.

“FitMi was easy to install and run. I wanted to focus on walking but I do all the exercises and quickly noticed an improvement in my stiff and awkward shoulder and weak hand. I also felt stronger when standing – steadier, walking quicker and more evenly. My foot is moving better. I can stand still for longer and my puppy no longer feels like she will topple me over when she jumps up!”

-Jill J.

Practice, practice, practice. Using and moving your legs on a consistent basis helps stimulate the brain and spark neuroplasticity. This is the best way to treat spasticity in the legs long-term.

[Related: Because walking is crucial for the activities of daily living, we created an extensive guide on how to regain the ability to walk if you’re working towards that goal.]

Contractures: When Spasticity Goes Untreated

By now, you understand the importance of exercise and how to add other therapies, such as electro-acupuncture, to increase your results. It’s also important to understand what happens when spasticity treatment is neglected.

If you don’t stretch or exercise your spastic muscles on a daily basis, then spasticity can progress into contractures, which are characterized by extreme stiffness in the muscles, joints, or connective tissue. Individuals with very limited mobility may neglect their affected limbs, which is another risk factor for the development of contractures (and also learned nonuse).

Contractures can be painful and further limit your range-of-motion. Individuals may experience contractures throughout their body, including in their hand, resulting in a clenched hand, or in the shoulder, resulting in frozen shoulder.

If you struggle with contractures, it’s important to start gently stretching your affected muscles. You may benefit from a hand splint or even stretching your hand out on a table.

Remember that spasticity increases the faster the muscles is stretched, so work slowly and gently. Never stretch to the point of pain. When contractures are involved, it’s a great idea to work more closely with a therapist. They can recommend other therapies or medications, such as orthotics or Botox when appropriate, and recommend exercises to do at home.

When Are Orthotics Appropriate?

Orthotics involve various casts and splits that help stretch spastic muscles. Your therapist may recommend orthotics if they are appropriate for you.

A common example is a hand splint. For those with spasticity resulting in a clenched hand, a splint can help prop open the hand to keep the fingers in an extended position for an extended period of time.

There are other types of orthoses available that target other muscle groups. For instance, an ankle-foot orthotic, which is commonly used for foot drop, can help stretch the calf and prevent contractures in the calf muscles.

As with all add-on therapies for spasticity, it’s important to combine the use of an orthotic with spasticity treatment exercises. Stretching and splinting alone is not enough to treat spasticity long-term. Instead, outcomes improve when orthotics and stretching are combined with additional therapeutic interventions.

Finding Relief from Spasticity

Spasticity involves rigid muscles and muscle stiffness that stems from miscommunication between the brain and muscles after a neurological injury. Exercise is a great treatment for spasticity because it sparks neuroplasticity and helps repair the communication between the brain and muscles.

There are many therapies available that you can supplement with your spasticity treatment exercises such as Botox and electro-acupuncture. You will see the best results when these extra therapies are added on top of your daily exercise regimen, which targets the root issue.