Hemiplegia, Spasticity and the Affected Arm After Stroke

Hemiplegia, spasticity and the affected arm after stroke

Walking usually comes back further than the arm does.

That is the pattern after most strokes with hemiplegia, and it is worth understanding early because it shapes how effort should be spent. The leg has a simpler job — a repetitive, weight-bearing, largely symmetrical cycle — and walking can be achieved with compensation: a stiff leg swung through, an ankle brace, a stick. The arm’s job is fine, varied, precisely graded manipulation, and there is no equivalent workaround. A hand that cannot grade its grip cannot be compensated into usefulness the way a leg can.

The result is that many stroke survivors walk reasonably and have an arm that does very little, and the arm then becomes a source of pain, stiffness and deformity rather than a limb they use.

This guide covers what happens to the affected side, what genuinely helps, and the preventable complications that cause most of the long-term trouble.

The sequence: flaccid, then spastic

Immediately after a stroke the affected limbs are usually flaccid — floppy, with no tone and no voluntary movement. Reflexes are absent or reduced.

Over the following days to weeks, tone typically increases. The limb becomes spastic: muscles resist being stretched quickly, reflexes become brisk, and the limb tends to settle into a characteristic posture — in the arm, shoulder pulled in and down, elbow bent, forearm turned palm-down, wrist and fingers flexed; in the leg, hip and knee extended with the ankle pointing down and inward.

Two things about spasticity are commonly misunderstood.

Spasticity is not the same as strength. A spastic arm is a weak arm with increased resting tone. Reducing the spasticity does not restore the strength, which is why treating spasticity in isolation often disappoints people who expected function to return.

Spasticity is not always the enemy. In the leg, a degree of extensor tone can be what allows a person to stand and take weight. Abolishing it entirely can leave someone less able to walk, not more. The clinical question is never “is there spasticity” but “is the spasticity causing a problem” — pain, difficulty with hygiene and dressing, contracture, or interference with function.

What makes spasticity worse

This list matters, because the first response to worsening tone should be to look for a cause rather than to escalate treatment:

• Pain anywhere, including pain the person cannot report
• Infection, especially urinary tract infection
• Constipation
• A full bladder
• Pressure areas or an ingrown toenail
• Cold
• Anxiety, stress or effort
• Poor positioning and badly fitted seating
• Tight clothing, a catheter strap, a shoe that doesn’t fit

A sudden increase in spasticity in a person with stroke is a flag to check for infection, constipation and pain before anything else — the same rule that applies to most neurological conditions.

The shoulder: the most preventable problem

The hemiplegic shoulder is where avoidable harm concentrates, and it is largely a handling problem.

The shoulder joint is inherently unstable, held together mostly by muscle rather than bone. When those muscles are flaccid or weak, the weight of the arm pulls the humerus down and out of the socket. That is subluxation — a partial dislocation — and it is common in the early weeks.

What follows is pain, and hemiplegic shoulder pain is frequently severe, frequently chronic, and interferes with everything: sleep, therapy participation, transfers, dressing, and the person’s willingness to use the arm at all.

The prevention is mostly about how the arm is handled, and it should be drummed into every family member and support worker:

Never pull on the affected arm. Not to assist a transfer, not to help someone stand, not to guide them. This is the single commonest cause of shoulder damage after stroke and it is entirely avoidable.

Support the arm when the person is sitting — on a pillow, an armrest, a lap tray — so it is not hanging.

Position it properly in bed, following the therapist’s instructions.

Move it through range gently, within the range taught, without forcing. Overhead pulley exercises in particular have been associated with shoulder injury and are generally discouraged.

Watch for the early signs: a palpable gap below the acromion, aching, pain at the end of range, or a person flinching during transfers.

Slings are contentious. They may reduce subluxation while worn and they also encourage the arm to stay in the flexed, adducted posture that leads to contracture, and they discourage use. Most teams use them selectively — for transfers and walking, not all day. Follow the therapist’s specific instruction rather than a general rule.

Preventing contracture

A contracture is a permanent shortening of muscle and soft tissue, so that a joint can no longer be moved through its range even passively. Once established it is extremely difficult to reverse, and it causes pain, prevents hygiene — a fisted hand macerating the palm is a genuinely nasty problem — and makes dressing and positioning hard.

Contracture develops when a limb spends long periods in a shortened position and is not moved. The prevention is daily movement through range and attention to positioning, and it is work that largely falls to family and support workers rather than to therapists, because it has to happen every day.

Here the guidelines contain something that surprises people. Hand and wrist splints are not recommended for routine use after stroke — a strong recommendation against, on the basis that trials showed no effect on function, pain or range of movement.

That does not mean no splint is ever indicated. It means that routine provision of a resting hand splint, which used to be standard, is not supported, and if a splint has been issued it is reasonable to ask what specific problem it is intended to solve and how anyone will know whether it is working.

What is supported for the limb more broadly is movement, positioning, weight-bearing through the affected side where safe, and active use.

Treatment for spasticity

In rough order of escalation.

Treat the aggravators first — the list above. A surprising amount of spasticity resolves when the constipation does.

Positioning and stretching, delivered daily rather than weekly. This is the foundation and it is unglamorous.

Task-specific activity and weight-bearing through the affected side.

Oral medications — baclofen, tizanidine, dantrolene, sometimes benzodiazepines. These act systemically, which is their weakness: the dose needed to reduce tone in one arm often causes sedation, weakness and cognitive dulling throughout. In a person already managing post-stroke fatigue and cognitive change, that trade-off is frequently a bad one. Worth reviewing if someone is on long-term oral antispasticity medication and is persistently drowsy.

Botulinum toxin injections into specific overactive muscles. This is the mainstay for focal spasticity and the advantage over oral medication is precision — the drug acts where it is injected, without systemic sedation. Effects take days to appear, last around three to four months, and need repeating. It is most useful for a clear focal problem: a fisted hand preventing hygiene, an elbow that cannot be straightened for dressing, an ankle that inverts and prevents a foot flat on the floor.

Two expectations to set. Botulinum toxin reduces tone; it does not restore strength or function by itself. And it works best combined with therapy in the weeks afterwards, when the reduced tone creates a window to stretch, position and practise. Injections without follow-up therapy waste much of the benefit.

Serial casting for established contracture, and in selected cases orthopaedic or neurosurgical intervention.

Getting the arm working again

The honest position is that arm recovery is harder than leg recovery and the results are more variable. But the approaches with evidence are specific, and knowing them lets you ask for the right thing.

Repetitive task-specific training for people with some voluntary movement. Not general exercise — practice of actual tasks, many times. The guidelines recommend it for the arm and hand where there is voluntary movement.

Constraint-induced movement therapy (CIMT) carries a strong recommendation for people who have some active wrist and finger extension: at least two hours of active therapy daily for two weeks, with the unaffected arm restrained at least six hours a day. The entry criterion is the limiting factor — a completely flaccid hand does not qualify — and the regime is demanding. Where it applies, the evidence is good.

Trunk restraint during active therapy sessions is strongly recommended at any stage, because people compensate by leaning rather than reaching.

Mirror therapy, mental practice and electrical stimulation are used in various protocols with varying evidence, and are reasonable to ask about.

Brain stimulation techniques should currently be used only in research settings for arm function, activities of daily living, aphasia and neglect.

And the thing that matters as much as any technique: use in daily life. An arm trained for an hour and then ignored for twenty-three does not consolidate. Stabilising a plate, holding a jar while the other hand opens it, carrying a light bag, pushing a drawer shut — these are the repetitions that make the difference, and support workers who do everything for the person remove them.

The leg, walking and foot drop

The leg gets less attention in writing about hemiplegia because it usually recovers further, but there are specific problems worth naming.

Foot drop is the commonest. Weakness of the muscles that lift the foot means the toes catch on the ground during swing, which causes trips and forces compensations — swinging the hip out, hitching the pelvis, vaulting on the good leg — that are tiring and hard on joints.

The standard answer is an ankle-foot orthosis (AFO), a brace that holds the ankle at ninety degrees. It is cheap relative to its effect, dramatically reduces trip risk, and usually improves walking speed and efficiency immediately. There are off-the-shelf and custom-moulded versions; custom costs more and fits better, which matters if it is worn all day.

Functional electrical stimulation (FES) is the alternative: a device that stimulates the nerve to lift the foot at the right moment in the gait cycle. It suits some people better than a brace, can have a training effect, and is more expensive and more fiddly. Worth asking about where an AFO is tolerated poorly.

Knee hyperextension — the knee snapping backward during weight-bearing — is common, damaging over time, and addressable with specific retraining and sometimes bracing.

Inversion, where the ankle rolls so weight falls on the outside of the foot, is both a falls risk and a pressure risk, and is one of the clearer indications for botulinum toxin.

And for walking generally, the guidelines recommend tailored repetitive practice, including circuit class therapy and treadmill training with or without body weight support. Walking is trained by walking, in quantity.

Sensation, and why it is underestimated

Hemiplegia is described as a movement problem, but a large share of people also lose sensation on the affected side — touch, temperature, pain, and critically proprioception, the sense of where the limb is in space.

Proprioceptive loss is disabling in a way that is hard to appreciate from outside. A hand that cannot feel what it is holding cannot grade its grip, so objects are crushed or dropped. A limb whose position is unknown has to be watched to be used, which means the person can only use the arm while looking at it. A foot that cannot feel the floor makes balance much harder in the dark.

Practical consequences worth acting on:

• Burns and scalds. Check water temperature for the person. An affected hand under a hot tap will not report it.
• Pressure and injury. Inspect the affected hand, arm and foot daily. Cuts, blisters and pressure areas go unnoticed.
• Hot surfaces, radiators and heat packs are a genuine hazard on an insensate limb.
• Footwear needs checking for stones and seams.

Sensory retraining has some evidence and is worth asking an occupational therapist about. But much of the management is environmental and habitual, and it falls to whoever is around.

Learned non-use, and why it matters

A concept worth knowing because it explains a lot.

After a stroke, using the affected arm is slow, difficult and unsuccessful. Using the good arm works. So people rationally switch to the good arm for everything, the affected arm gets no practice, and the brain’s representation of it shrinks further from disuse. The arm then becomes less capable than the underlying damage dictates.

This is learned non-use, and it is the reason CIMT works by restraining the good arm.

The practical implication for families and support workers: every time you hand something to the good side, or do a task that the affected arm could have attempted, you are participating in this. The counter is deliberate — put the drink on the affected side, set up tasks that require two hands, build in use rather than efficiency. It is slower. That is the point.

Central post-stroke pain

Distinct from shoulder pain and frequently missed for years.

Some strokes, particularly those involving the thalamus or sensory pathways, produce central post-stroke pain: burning, aching, stabbing or electric-shock sensations on the affected side, often with the paradoxical combination of numbness and pain in the same area. Light touch or cool air can be experienced as painful.

It typically begins weeks to months after the stroke, which is part of why it gets attributed to something else. It does not respond well to ordinary analgesics — paracetamol and anti-inflammatories are largely ineffective — and the drugs that help are the neuropathic agents such as amitriptyline, gabapentin, pregabalin or duloxetine, used at doses titrated slowly.

The reason to name it: people live with it unnecessarily, because they report pain, are given paracetamol, find it useless, and stop mentioning it. If someone describes burning or shock-like pain on the affected side, say the words “central post-stroke pain” to the doctor.