After a stroke, many individuals experience changes in their muscles and movement abilities. One common challenge is muscle hypertonicity, a condition where the muscles become overly tight, making it difficult for a person to move freely. This can significantly impact daily activities like self-feeding, bathing, and walking.
The following article will explain the connection between stroke and hypertonicity and the strategies that survivors can use to manage hypertonicity and potentially improve their quality of life.
What is Hypertonicity?
Muscle hypertonicity and spasticity are common conditions that can significantly impact movement and daily function for stroke survivors.
Defining Hypertonicity:
Muscle hypertonicity happens when muscles become overly tight or stiff, making it difficult for a person to relax the muscle or muscle groups normally (1). Muscle hypertonicity can cause spasticity, where muscles tighten by themselves. Spasticity refers to the involuntary “drawing in” or “pulling” of muscles, causing the affected limb to feel stiff, tight, or difficult to move.
For stroke survivors, up to 43% may experience spasticity in the first year following their stroke, with many facing long-term challenges such as hypertonicity (2, 3).
Causes of Hypertonicity:
A stroke causes damage to the brain, making it harder to send messages to the muscles. As a result, the muscles get mixed signals, leading to tightness even without intentional movement. Over time, joints may also become stiffer, further limiting mobility.
The Importance of Occupational and Physical Therapy
To prevent hypertonicity and joints from becoming locked or “frozen,” occupational and physical therapists (OT and/or PT) use passive range-of-motion exercises, joint mobility, stretching, splinting, and other modalities. These exercises support joint flexibility and muscle activity, helping patients regain movement. As paralysis improves, patients should engage in range-of-motion and other therapeutic activities that encourage functional mobility. Without ongoing management, hypertonicity may become permanent, making it much harder to move.
The Emotional Impact of Hypertonicity
Recovering from a stroke in both early and chronic stages can be incredibly challenging. Hypertonicity and spasticity can feel discouraging, leaving some stroke survivors feeling overwhelmed and tempted to give up on therapy. Skipping movement and exercises can cause muscles and tendons to tighten permanently, leading to painful contractures and loss of mobility in parts of the body.
Hypertonicity and Stroke
Stroke can cause muscle stiffness or weakness, which limits movement and highlights the need for therapy to improve flexibility and strength.
How Stroke Leads to Hypertonicity:
After a stroke, many people experience weakness or paralysis on one side of the body, which often limits their ability to move their affected limbs. Immobility and non-use of the limb can lead to muscle stiffness, weakness, and functional challenges over time.
Types of Hypertonicity after Stroke:
Rigidity
Hypertonicity often causes muscle rigidity, making it difficult for a person to do everyday activities. Rigidity can limit how joints move, especially in joints like the elbow, which works like both a hinge and a pivot. If not used, the joint can become “frozen”, making movement even more challenging. This can lead to a loss of independence, making participation in therapy even more essential to reduce rigidity and improve range-of-motion.
Spasticity
Muscle spasticity involves involuntary muscle movements of “jerking”. Like rigidity, this can affect a person’s ability to perform daily tasks. Rigidity and spasticity often occur together, emphasizing the importance of regular therapy to address both issues.
Effects of Hypertonicity on Daily Life
Hypertonicity can affect arms and legs, making it painful to move and harder to perform basic tasks, which can reduce independence.
Physical Impact:
In stroke survivors, hypertonicity often affects the arms more significantly than the legs (5). Around 43% of individuals with one-sided paralysis have spasticity in at least one limb six months after their stroke (6). This condition can lead to abnormal body positions and walking patterns, such as Flexor Synergy Posture. Whether or not a stroke survivor has this posture, hypertonicity can make everyday self-care activities challenging. It can also lead to:
- Chronic pain in the affected limbs
- Difficulty with moving, particularly when climbing stairs
- Complications in managing other health disorders (7)
- Reduced personal independence and overall quality-of-life
Mental Impact:
One-third of all stroke survivors are diagnosed with depression (8). Additional common challenges include:
- Increased anxiety
- Difficulty concentrating
- Persistent fatigue
These mental impacts can make it more difficult for stroke survivors to engage in OT and/or PT exercises. Even if they participate during therapy sessions, they may struggle to maintain a daily exercise routine at home, which is vital for recovery. This lack of motivation can hinder progress, regardless of whether or not the stroke survivor has hypertonicity.
Management and Treatment of Hypertonicity
Treatment for hypertonicity after a stroke includes therapy and sometimes medical help to reduce muscle stiffness and improve movement.
Managing hypertonicity after a stroke involves various treatment options with a focus on OT and/or PT. However, if spasticity is severe and causes chronic pain or self-injury, then medical treatments may be considered.
A Team Approach to Recovery
Recovering from a stroke is best experienced through a collaborative effort involving a team of healthcare professionals. This team often includes:
- Neurologists: Specialists in brain and nervous system function
- Rehabilitation Nurses: Assist with daily care and recovery
- Social Workers and Mental Health Counselors: Support emotional and social needs as well as coordination of care
- Occupational Therapists and/or Physical Therapists: Focus on improving mobility and daily functioning
- Speech-Language Therapists: Assist with communication challenges
Team members should practice clear communication to enable the collaboration essential for providing comprehensive care. For example, occupational therapists can help stroke survivors regain the ability to follow instructions for daily activities, while speech-language therapists can help them re-learn how to communicate with words.
Occupational and Physical Therapy Exercises and Techniques:
OT and/or PT rehabilitation services can help stroke survivors manage and improve hypertonicity to enhance mobility, function, and quality of life. Therapists employ a variety of exercises and techniques to manage hypertonicity and enhance recovery of stroke survivors:
- Stretching and range-of-motion exercises: Improves flexibility and reduces stiffness
- Muscle re-education: Helps relearn coordinated movements
- Manual therapy: Hands-on techniques to manipulate muscles, joints, and other soft tissues
- Splinting and orthotics: Reduce joint pain and spasticity, and improve movement
- Proper positioning: Positioning the body correctly to perform a coordinated movement, for example, positioning the thumb and fingers to pick up a spoon
- Brain plasticity techniques: Mirror therapy, mental practice, and more to encourage brain plasticity for more control and awareness of muscles. Mirroring involves the therapist demonstrating positioning and movements for the stroke survivor to observe and replicate
- Understanding (and avoiding) triggers, when possible: Pain, stress/anxiety, temperature changes, internal medical issues (UTI), sudden alarm to nervous system (i.e. loud noise), improper positioning
- Massage and Transcutaneous Electronic Nerve Stimulation: May relieve muscle tension and promote relaxation.
- Heat/cold applications: Helps manage pain and spasticity.
- Adaptive equipment and assistive devices: Tools to aid in performing exercises at home
- Functional tasks: Basic activities such as feeding and dressing
Medical Interventions
For severe hypertonicity, doctors may suggest medications or surgery to relax muscles and help stroke survivors regain control.
When hypertonicity causes chronic pain or continues despite extensive OT and/or PT, medical interventions may be recommended. These can include various medications and surgical procedures in some cases.
There are two main types of medicines to reduce spasticity:
- Systemic medications: Work on the brain and nervous system to help reduce spasticity throughout the body
- Peripherally-acting drugs: Target specific muscles, nerves, or tendons to relieve spasticity in certain areas
Several interventional drugs are available to reduce hypertonicity, including the following (9, 10):
- Skeletal muscle relaxants
- Alpha2-adrenergic agonists
- Anticonvulsants, such as benzodiazepines and Gabapentin
- Intrathecal Baclofen, which is delivered through a catheter directly into the spine
- Phenol and alcohol nerve blocks to reduce spasticity
- Botulinum Toxin injections
If other treatments haven’t been effective or if a permanent deformity has developed that can’t be corrected without surgery, surgical options may be considered (11). Some common surgical interventions include:
- Intrathecal baclofen pump placement: Delivers medication directly into the central nervous system, or a muscle, nerve, or tendon
- Selective dorsal rhizotomy: A neurosurgical procedure that cuts specific nerve roots in the spinal cord to reduce spasticity
- Tendon release or tendon shortening: Procedures to improve muscle function and reduce stiffness.
- Orthopedic procedures: Surgery for joint stabilization to improve balance and walking ability
Improving Life with Hypertonicity: Key Takeaways for Stroke Recovery
Many stroke survivors with one-sided paralysis face hypertonicity and spasticity as part of their recovery. As paralysis subsides and nerve signals start to return, spasticity can emerge due to miscommunication between the brain and muscles. This can make coordinated movements and daily activities challenging.
While spasticity can be frustrating, consistently performing prescribed OT and/or PT exercises, both during sessions and daily at home, is essential for improving motor skills and independence. If hypertonicity persists despite therapy, medications or surgery may be recommended.
Additionally, cognitive impairments resulting from a stroke can complicate exercises efforts. However, engaging in rehabilitation not only aids physical recovery but also supports cognitive improvement by promoting neuroplasticity. Participating in a comprehensive stroke rehab program is vital to achieving full recovery and returning to a more independent lifestyle.
References:
- BrainFacts.org. Hypertonia. Webpage: https://www.brainfacts.org/diseases-and-disorders/neurological-disorders-az/diseases-a-to-z-from-ninds/hypertonia
- American Stroke Association. Spasticity after Stroke. Webpage: https://www.stroke.org/-/media/stroke-files/lets-talk-about-stroke/life-after-stroke/ltas_spasticity_english_0419.pdf?la=en
- Takeuchi K, Takebayashi T, Hanioka D, et al.(2024). Comparison of tendon and muscle belly vibratory stimulation in the treatment of post-stroke upper extremity spasticity: A retrospective observational pilot study. Scientific Reports14: 4151. Webpage: https://www.nature.com/articles/s41598-024-54815-1#:~:text=Upper%20extremity%20spasticity%20occurs%20in,in%20the%20lower%20extremities2.
- Allison R, Shenton L, Bamforth K, et al. (2016). Incidence, Time Course and Predictors of Impairments Relating to Caring for the Profoundly Affected Arm after Stroke: A Systematic Review. Physiotherapy Research International 21(4): 210-227. Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5157782/
- Homola A. (2021). The Modern View of Physical Therapy on Recovery of Patients after Stroke with Upper Limb Spasticity. Scientific Journal of Polonia University 48(5): 159-164. Webpage: http://pnap.ap.edu.pl/index.php/pnap/article/view/798
- Kuo C-L, and Hu G-C. (2018). Post-stroke Spasticity: A Review of Epidemiology, Pathophysiology, and Treatments. International Journal of Gerontology 12(4): 280-284. Webpage: https://www.sciencedirect.com/science/article/pii/S1873959818300073
- Takanori R, Tetsuo O, Tsukasa S, et al. (2020). Spasticity and Range of Motion Over Time in Stroke Patients Who Received Multiple-Dose Botulinum Toxin Therapy. Journal of Stroke and Cerebrovascular Diseases 29(1): 104481. Webpage: https://www.sciencedirect.com/science/article/abs/pii/S1052305719305658
- Towfighi A, Ovbiagele B, El Husseini N, et al. (2016). Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 48(2): e30-e43. Webpage: https://www.ahajournals.org/doi/10.1161/str.0000000000000113
- Chang E, Ghosh N, Yanni D, et al. (2013). A Review of Spasticity Treatments: Pharmacological and Interventional Approaches. Critical Reviews in Physical and Rehabilitation Medicine 25(1-2): 11-22. Webpage: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349402/
- Bakheit AM. (2012). The pharmacological management of post-stroke muscle spasticity. Drugs & Aging 29(12): 941-947. Webpage: https://pubmed.ncbi.nlm.nih.gov/23138834/
- Francisco GE, Wissel J, Platz T, et al. (2021). Post-Stroke Spasticity. In: Platz T (Editor). Clinical Pathways in Stroke Rehabilitation: Evidence-based Clinical Practice Recommendations [Internet]. Springer, Cham: Edinburgh, Scotland, UK. Webpage: https://www.ncbi.nlm.nih.gov/books/NBK585580/
