Spasticity or hypertonicity is a common and often frustrating problem after stroke, brain injury, spinal cord injury, and in long-term neurological conditions such as multiple sclerosis and cerebral palsy. [1][2] It causes involuntary muscle stiffness and overactivity, which can lead to tight, heavy limbs, spasms, pain and difficulty moving. [1][2]
If it is not managed early, spasticity can lead to poor posture, pain, problems with washing and dressing, reduced mobility, and eventually fixed contractures where joints no longer move properly. [3][1] The good news is that with the right physiotherapy, positioning and daily routines, many of these problems can be reduced or prevented. [2][4]
What is spasticity?
In simple terms, spasticity is involuntary muscle stiffness caused by damage to the brain or spinal cord. [1] Nerve pathways between the brain, spinal cord and muscles no longer work smoothly, so messages that should turn muscles on and off become unbalanced. [1][2]
This can lead to:
- Stiff or rigid muscles that resist movement.
- Sudden spasms where the limb bends or shoots out.
- Repetitive movements such as foot tapping are known as clonus.
- A feeling of heaviness, tightness or pulling.
- Pain is linked to stiffness or poor positioning. [1][2]
Spasticity can affect any part of the body. [2] You may notice a clenched hand, a bent elbow, a pointed foot, thighs that pull together, or a trunk that is difficult to sit upright. [2] Symptoms often vary throughout the day and may be worse when you are tired, in pain, unwell or stressed. [1][2]
Why early action matters
When a muscle is held in a shortened position for a long time, the soft tissues gradually adapt. [3] Muscles shorten, tendons and ligaments tighten, and the joint loses range of movement; if this continues, the limb can become fixed in one position. [3]
This is why early management is so important:
- A hand that stays tightly closed for months is much harder to open later.
- An ankle that is always pointed down makes standing and walking more difficult.
- A knee that never fully straightens affects transfers and posture. [3][4]
National guidance emphasises early identification of spasticity, good positioning from the start, and timely physical management to prevent long-term complications. [3][5]
How spasticity affects daily life
Spasticity is not just about stiff muscles; it can affect standing, walking, transfers, dressing, washing, sleeping and general comfort. [1][2] It can also increase the physical strain on family members and carers because everyday tasks become harder and sometimes painful. [1]
Skin health is a particular concern. In a tightly closed hand, fingernails can press into the palm and damage the skin, and it can be hard to clean and dry the area properly. [2] In other areas, poor posture and pressure can lead to sore skin, pressure injuries and pain if they are not picked up early. [3][2]
What makes spasticity worse?
Spasticity is very sensitive to what is going on elsewhere in the body. [1] Common triggers include pain, urinary tract infections, urinary retention, constipation, red or broken skin, pressure areas, poor seating, tight clothing, fatigue, stress, and extreme temperatures. [1][4][2]
If spasticity suddenly worsens, it is important to look for and treat these triggers rather than assuming the condition itself has simply progressed. [1] Cold often makes stiffness worse, while warmth can help muscles relax temporarily and may make stretching easier. [4][2]
How physiotherapy helps
Physiotherapy is at the heart of spasticity management because it addresses both the physical changes in muscles and joints and the way spasticity affects everyday activities. [2][3] A specialist neurological physiotherapist will assess which muscles are stiff, which are weak, how posture is affected, and how spasticity is affecting day-to-day function. [2]
Treatment often includes:
- Regular stretching and range-of-movement exercises.
- Positioning strategies for bed, chair and wheelchair.
- Strengthening weak muscles to support better posture.
- Task-specific practice such as standing, stepping or transfers.
- Advice and training for carers on safe handling, stretching and positioning.
- Splints or orthoses when needed to help maintain position or muscle length. [2][3][4]
Splints and braces can be helpful, but only when they are comfortable, correctly fitted and used consistently. [3] The aim is gentle, sustained stretch over time rather than forceful stretching. [3][4]
Using tone wisely
Spasticity should not simply be “switched off” everywhere. [1] Sometimes a small amount of tone can help a weak leg stay stable enough for standing or transfers, while excessive tone in the hand, calf, or inner thighs may need to be reduced because it interferes with care or movement. [1][2]
This is why specialist assessment matters. The same amount of tone may help in one situation and hinder in another, so treatment needs to be tailored to the person and their goals[5][2]. This is the most important role of a physiotherapist – to assess and plan where increased tone will actually help with functional outcomes and tailor the programme. This is where the “art” of physiotherapy comes in.
Massage and hands-on techniques
Hands-on treatment can sometimes reduce spasticity in the short term, but the way it is done matters. [4][2] Slow, gentle movements and sustained stretches are generally preferred because fast, forceful movements can trigger the stretch reflex and increase spasticity. [4][2]
If family members or carers want to help with massage or stretching, it is best for a physiotherapist to show them safe techniques and a simple routine that fits daily life. [3][2]
Shockwave therapy: an adjunct, not a stand-alone treatment
Extracorporeal shockwave therapy is another adjunct that has a growing body of evidence recently in the treatment of spasticity in some patients. Extracorporeal shockwave therapy may be useful for some people with spasticity as part of a broader treatment plan, but it should not be presented as a stand-alone solution. [2] At Axis Physiotherapy, it is used selectively for appropriate patients alongside standard neurological physiotherapy, stretching, positioning, strengthening and functional training. In the patients we have used here at Axis Physiotherapy, we found the outcomes very good – often just within the first session.
In clinical practice, it has been associated with encouraging improvements in muscle softness, ease of stretching and movement in some patients, but outcomes vary, and treatment should always be guided by individual assessment and goals.
Medication and medical treatments
For some people, physical management alone is not enough, and medication may be needed. Common drugs used in spasticity management include baclofen, tizanidine, diazepam, clonazepam, dantrolene, gabapentin and pregabalin. [1][2]
As part of a structured spasticity service, assessment should include whether muscle-relaxant medication is likely to help. Where appropriate, clear written recommendations can be provided to the GP on which medication to consider, suggested starting doses and how to titrate the dose gradually. [3][5] Ongoing monitoring is important so that response, side-effects and function can be reviewed and the prescription adjusted over time to find the lowest effective dose. [3][5]
If spasticity remains problematic despite good physical management and oral medication, other options can be considered through specialist services, such as botulinum toxin injections or intrathecal baclofen in selected cases. [3][5] These treatments should always be combined with physiotherapy, stretching, splinting and goal-directed rehabilitation rather than used in isolation. [3][5] At Axis Physiotherapy, we assess and engage with the GP regarding medications and titrations as appropriate.
Practical tips for patients and carers
Look after the skin in a tight hand
- Check the hand daily for redness, moisture, smell or broken skin.
- Keep nails short and smooth to avoid scratching the palm.
- Clean and dry the palm and between the fingers as comfortably as possible.
- Ask a therapist to show safe ways to gently open the hand for care. [2]
Prioritise movement over products
- Regular stretching, movement, standing and walking where safe help more than creams or oils.
- Moisturisers can help dry skin, but they do not treat the neurological cause of spasticity.
- Short and regular movement sessions are usually more realistic than one long daily session. [4][2]
Use splints and supports consistently
- Follow the wearing schedule advised by the therapist.
- Report rubbing, pain or skin marks quickly.
- Benefit usually comes from long-duration, gentle stretches rather than force. [3][4]
Check seating and bed positioning
- In sitting, aim for the hips right back in the chair with feet supported.
- Use cushions or supports to help keep the trunk upright and the arms well-positioned.
- In bed, use pillows to keep joints in a more neutral and comfortable position.
- Ask for a review if there is leaning, sliding or increased spasms in sitting or lying. [4][2]
- Do not put pillows under the knees – this action will further shorten the back of the leg muscles, mainly the hamstrings.
Watch for silent loss of movement
- Check daily whether the hand opens, the elbow straightens, and the ankle comes up towards the body.
- Report gradual changes early because it is easier to maintain a range than to regain it later. [3][2]
Act quickly on triggers
- Seek help promptly for possible infections.
- Treat constipation early.
- Make sure clothing and splints are not too tight.
- Monitor new pain, pressure areas or major changes in sleep or mood. [1][2]
Why home physiotherapy can work so well
Home physiotherapy can be especially effective because treatment happens in the place where real life takes place. [4][2] Seating, bed setup, transfers, washing, dressing and carer handling can all be assessed directly in context. [4][2]
This also allows carers and family members to be involved properly. When they understand how to position a limb, help with stretching, open a hand safely, or set up a chair well, the benefits of treatment extend beyond the therapy session itself. [1][2]
Who does this apply to
The principles in this guide apply to people living with post-stroke spasticity, traumatic or acquired brain injury, multiple sclerosis, cerebral palsy, spinal cord injury and other neurological conditions where increased tone affects comfort, movement, posture and care. [1][2][5]
Spasticity management is not just about loosening tight muscles. It is about protecting posture, preserving movement, reducing pain, making care easier and using tone wisely where it helps function while reducing it where it gets in the way. [3][5] With early action, consistent follow-through and specialist neurological physiotherapy, many patients and families see meaningful and practical improvements in daily life. [4][2]
Further reading and references:
- Oxford University Hospitals NHS Foundation Trust (2021) Physical management of spasticity. Oxford: OUH.ouh
- Royal College of Physicians (2019) Spasticity in adults: management using botulinum toxin. London: RCP.rcp+1
- NHS Lothian (2018) A guide to managing spasticity. Edinburgh: NHS Lothian. nhslothian
- West Suffolk NHS Foundation Trust (2021). Tone management advice: positioning for spasticity. Bury St Edmunds: WSH NHS FT.wsh
- Ashford, S. and Turner-Stokes, L. (2013) ‘Management of spasticity in adults: practical guidance for clinicians’, Clinical Medicine, 13(5), pp. 496–501.journals.sagepub
- Ada, L., Dorsch, S. and Canning, C.G. (2006) ‘Strengthening interventions for post-stroke weakness’, Stroke, 37(1), pp. 239–240. (for strengthening/functional training principles)ouci.dntb
- Suputtitada, A. et al. (2024) ‘Best practice guidelines for the management of patients with post-stroke spasticity’, Toxins, 16(2), 98.ouci.dntb