Are muscle spasms common after a stroke?

Muscle Spasms After Stroke: Prevalence and Management

Yes, muscle spasms are common after stroke, affecting approximately 20-30% of all stroke survivors, with higher prevalence in the upper limbs compared to lower limbs. 1

Prevalence and Characteristics of Post-Stroke Spasticity

• Spasticity, characterized by velocity-dependent resistance to stretch of a muscle, is a component of the upper motor neuron syndrome that commonly manifests as muscle spasms 2
• The prevalence of post-stroke spasticity in any limb ranges from 25% to 43% over the first year after stroke 2
• Spasticity is more common in the upper limbs than the lower limbs and appears to be more prevalent among younger stroke survivors 1
• Spasticity can develop as early as 2 months post-stroke and may be accompanied by muscle contractures 3

Physiological Mechanisms

• Post-stroke spasticity results from a combination of neural and muscular changes:
  • Reticulospinal hyperexcitability due to maladaptive plasticity is the most plausible mechanism for post-stroke spasticity 4
  • Skeletal muscle changes include denervation, disuse, inflammation, remodeling, and fiber-type shifts 5
  • On the stroke-affected side, there is severe muscle wasting, increased intramuscular fat, and a shift from slow-twitch toward fast-twitch "fatigable" muscle fiber characteristics 2

Impact on Function and Quality of Life

• Spasticity is correlated with activity limitations associated with hygiene, dressing, and pain 2
• When spasticity is present, the cost of care is 4 times higher than when spasticity is absent 2
• Spasticity contributes to poststroke fatigue, which is common with a prevalence rate from 35% to 92% 2
• Muscle spasms can significantly impair quality of life and increase caregiver burden 2

Management Approaches

Non-pharmacological Interventions

• First-line approaches include:
  • Antispastic positioning, range of motion exercises, stretching, splinting, and serial casting 6
  • Physical modalities such as neuromuscular electrical stimulation (NMES) or vibration applied to spastic muscles may temporarily improve spasticity 2
  • Strengthening exercises should be included in rehabilitation of patients with muscle weakness after stroke 2

Pharmacological Management

• For focal spasticity:

  • Targeted injection of botulinum toxin into localized upper limb muscles is recommended to reduce spasticity, improve range of motion, and improve dressing, hygiene, and limb positioning 2, 7
  • Botulinum toxin injections into lower limb muscles are recommended to reduce spasticity that interferes with gait function 2

• For generalized spasticity:

  • Oral antispasticity agents (such as baclofen, tizanidine, or dantrolene) can be useful but may result in dose-limiting sedation or other side effects 2, 6
  • Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions 2, 6

Important Clinical Considerations

• Muscle weakness is often more limiting than spasticity itself, so strengthening should be emphasized in rehabilitation 3
• Early management and adequate physical therapy are essential to avoid muscle shortening, pain, and their consequences 7
• Proper selection of muscles and individualized treatment approaches can improve function in selected post-stroke patients 7
• Exercise after stroke can improve cardiovascular fitness, walking ability, and upper-extremity muscle strength, which may indirectly help manage spasticity 2

Monitoring and Assessment

• The Modified Ashworth Scale is the most common instrument used to grade spasticity after stroke, measuring both biomechanical and neural components in passive stretch 1
• Regular assessment of spasticity is important as it may change over the course of recovery 4
• Spasticity may emerge and disappear in the course of complete motor recovery, so ongoing monitoring is essential 4