Published by Unseen Progress, an independent publisher of caregiver research. Last reviewed 2026-05-10. Part of the stroke caregiver research overview.
Short answer. Spasticity affects roughly 30–40% of stroke survivors at some point, particularly in the first year (Wissel et al., 2013). Contractures — fixed shortening of muscles and connective tissue — are largely preventable with consistent positioning, active movement, and selective stretching, but they are not primarily prevented by passive stretching alone (Harvey et al., 2017). The AHA/ASA guidelines (Winstein et al., 2016) emphasise active task-specific practice as the first-line intervention, with botulinum toxin for focal spasticity that interferes with function, and combined approaches for established contractures.
Spasticity is a velocity-dependent increase in muscle tone — the faster you move a limb passively, the more it resists. It results from disrupted descending motor control after stroke and is one component of upper motor neuron syndrome, alongside weakness, loss of dexterity, and abnormal reflexes. Spasticity is not the same as stiffness, contracture, or pain, though all four often coexist.
A contracture, by contrast, is a structural change — the muscle, tendon, and connective tissue around a joint physically shorten, so the joint cannot move through its full range even with the muscle relaxed. Once established, contractures are difficult to reverse. The clinical goal is to prevent them, not to treat them.
The most consistent finding in the rehabilitation literature is that active movement protects range of motion better than passive stretching. Lang and colleagues (Lang et al., 2009) documented that the actual repetition counts in standard stroke outpatient sessions are far below what the literature suggests is needed for motor recovery, and the same dose-response applies to range preservation. A limb that is used — even with significant weakness — is far less likely to develop a contracture than a limb that is only stretched.
Harvey, Katalinic, Herbert, and colleagues' Cochrane review (Harvey et al., 2017) of stretching for the prevention and treatment of contractures concluded that stretching alone, when applied for less than seven months, does not have clinically meaningful effects on joint mobility, pain, or quality of life in people with neurological conditions. This is a significant finding for families: hours of passive stretching, on its own, are not the right protocol. Stretching has a place — typically as part of a positioning regimen and as preparation for active practice — but it is not the protective mechanism most families have been told it is.
Spending hours in the same position with the affected limb in a shortened range is one of the strongest contributors to contracture development. Side-lying, supine, and seated positions that hold the elbow flexed, the wrist flexed, and the fingers curled are particularly common after stroke. Varying position throughout the day, supporting the affected limb in a more extended range during rest, and avoiding prolonged shortening are higher-yield interventions than dedicated stretch sessions.
Resting hand splints, ankle-foot orthoses, and similar devices have a role for specific situations: maintaining range during prolonged rest, supporting function during activity, and preventing predictable shortening. They are not blanket solutions and should be prescribed and fitted by an OT or PT — over-aggressive splinting can cause skin breakdown, pain, and learned non-use.
For specific muscles where spasticity interferes with function or hygiene (a tightly fisted hand that cannot be cleaned, a flexed elbow that prevents dressing, a plantarflexed foot that catches in walking), botulinum toxin injections have strong evidence (Winstein et al., 2016). The injection reduces tone in the targeted muscle for 3–4 months, opening a window in which active practice and stretching are more effective.
Oral antispasticity medications (baclofen, tizanidine, dantrolene) have a role in some cases but are limited by side effects, particularly fatigue and weakness, which can directly compete with rehabilitation. They are typically reserved for severe generalised spasticity rather than first-line.
The single most protective home intervention is active practice of the affected limb in the activities the survivor wants back — reaching for a cup, buttoning a shirt, carrying a load while walking. Even with significant weakness, attempted active movement preserves range better than passive stretching alone.
Audit where the affected limb is during rest. If the elbow is flexed in a sling for hours, the wrist curled, the fingers folded, the position is contributing to shortening. Discuss with OT how to vary positioning — and how to support the limb in a more extended range during sleep and prolonged sitting.
Stretching has a place — particularly before active practice, and as part of a positioning protocol. It is not the headline intervention.
Spasticity itself is not the primary outcome. Function is. Track what the survivor can do — distance reached, items grasped, time to dress one arm — month over month. If function is improving, the spasticity is being managed adequately for the goals that matter.
Pain that does not resolve, sudden increase in tone, skin breakdown under a splint, loss of range that had previously been present — these warrant a call to the rehab team. Early intervention is much easier than late.
1. Get a current OT/PT assessment of the affected limb's range, tone, and functional capacity. 2. Build the home protocol around active practice of the survivor's actual goals. 3. Add positioning and stretching as supports, not as the main act. 4. Discuss botulinum toxin with the team if focal spasticity is interfering with function or hygiene. 5. Track range and function monthly. Look at the trend, not the day.
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