Fingers that stay clenched and will not open. An elbow that bends and will not straighten. A foot that points down and turns inward while walking.
After a stroke, a spinal cord injury or a similar condition, patients and families often ask the same thing: we are already working hard at rehabilitation, so why does the body still feel so tight — and why does movement become harder the more anxious and the harder we try? Spasticity is often part of the answer.
Episode 40 of JianJia Rehabilitation's Rehab Experts series invited Ying Zhiya, TCM attending physician and supervising rehabilitation therapist at Fuzhou Jianjia Rehabilitation Hospital, to speak on "Why won't the muscle relax? Decoding precision intervention for spasticity". This article summarises the assessment, intervention and day-to-day management covered in that session.
Ying Zhiya
TCM attending physician and supervising rehabilitation therapist, Fuzhou Jianjia Rehabilitation Hospital
When muscles stay tight, the problem may lie in neural control
Normally the nervous system coordinates contraction and relaxation, so that reaching, lifting a leg or walking happens smoothly.
When a stroke, traumatic brain injury or spinal cord injury disturbs that control, some muscles can enter an abnormally heightened state of tension. One important feature of spasticity is this: when the limb is moved passively, the faster the movement, the more resistance you may feel.
It is not the same as the occasional cramp after exercise, and it cannot be judged simply by how "hard" the limb feels. If movement stays limited for a long time, muscle, tendon and other soft tissue may also shorten — a contracture — which makes the joint even harder to move. Persistent stiffness, or any change in function, deserves a rehabilitation assessment.
The first step in precision care is understanding why movement fails
A hand that will not open or a leg that will not straighten can have different causes: abnormal muscle over-activity, soft-tissue shortening that has already developed, or both at once alongside weakness, pain and joint problems.
The session introduced assessment tools such as the Modified Ashworth Scale and the Tardieu Scale. Clinicians combine the resistance felt at different speeds of passive movement, the range of motion at the joint, and what the patient can actually do.
For patients and families, it helps to be able to describe three things clearly: where it is tight, when it is worse, and what it interferes with most.
Is it hard to clean the palm, or painful to get dressed? Is the sole difficult to place flat on the floor, or do you trip easily when stepping? These concrete problems help the rehabilitation team set the goals of treatment. Spasticity management is about tone, but even more about whether the patient can carry out daily activities more comfortably and more easily.
Three kinds of intervention, each with its own place
For different problems, the session focused on extracorporeal shockwave therapy, ultrasound-guided needle-knife, and botulinum toxin injection. They work in different ways, are chosen only after assessment, and are combined with rehabilitation training.
Extracorporeal shockwave therapy: an adjunct worth considering
Shockwave therapy uses a device to generate mechanical waves that act on the target tissue. For some patients it may help reduce muscle tightness or related pain in the short term, creating a window for the training that follows.
The treatment site, intensity and number of sessions have to be set for the individual case. Local pain or discomfort can occur during treatment; it does not suit everyone, and it cannot replace functional training.
Ultrasound-guided needle-knife: chosen with care for specific soft-tissue problems
The session also covered needle-knife technique under ultrasound guidance. The physician uses imaging to observe the layers of tissue and the nearby nerves and blood vessels, then works on specific soft-tissue problems that assessment has identified.
A distinction matters here: spasticity caused by disturbed neural control and contracture caused by shortened soft tissue are not the same thing. Whether needle-knife is appropriate, and what it can realistically be expected to improve, is a decision for a specialist. Imaging helps with localisation, but the risks of bleeding, infection and tissue injury remain — it should not be treated as a routine option for everyone with spasticity.
Botulinum toxin injection: reducing over-contraction in target muscles
Botulinum toxin inhibits the release of acetylcholine at the neuromuscular junction, reducing over-contraction of the target muscles. It is one of the common approaches to focal spasticity.
The physician selects which muscles to inject, the dose and the method of localisation according to the patient's functional goals. Its effect is time-limited, so regular re-assessment is needed, and local weakness and other adverse effects can occur.
Once the muscle has relaxed, targeted training is still needed to practise the movements — that is how the change produced by treatment becomes a change in daily ability.
Rehabilitation training has to reach into daily life
Lowering muscle tone does not mean that grasping, standing or walking will come back by itself. Patients may also need to improve strength, balance and movement control.
The session described the role of physiotherapy and occupational therapy in functional recovery. The rehabilitation team arranges positioning, joint mobility work, active movement and functional training according to the patient's ability, and builds the practice into real tasks.
Dressing becomes practice for involving the upper limb; picking up a cup becomes practice for reaching, gripping and releasing; walking safely becomes practice for shifting weight and stepping.
Whether training is appropriate cannot be judged by the number of repetitions or by how much the patient sweats. It has to be judged by movement quality, by how pain changes, and by what the patient can actually complete.
For patients whose fingers flex and will not open, repeatedly squeezing a ball as hard as possible should not be adopted as a universal exercise. What to practise, and for how long, should be guided by the therapist after assessment.
Back home, families can do four things
1. Learn to assist properly, without pulling or forcing
Ask the therapist to teach you positioning and assisted movement that suit this patient. Movements should be slow and gentle, and stay within the range you have been shown; if pain or resistance increases markedly, do not push on.
2. Watch for tightness that suddenly gets worse
If spasticity is clearly worse than usual, look for accompanying problems such as pain, constipation, urinary difficulties or broken skin, and raise them with the clinical team. Do not simply respond by adding more training.
3. Record real changes in daily life
Beyond asking "is it looser?", note whether dressing has become easier, whether cleaning is more convenient, and whether night pain has decreased. These notes are useful at follow-up.
4. Keep to re-assessment and adjust the plan
A rehabilitation plan has to change as the condition and the patient's ability change. Do not adjust medication on your own, and do not copy another patient's training programme.
Let every improvement land in real life
Managing spasticity needs professional assessment, appropriate treatment, sustained training and family support working together.
For the patient, progress may be a palm that is easier to clean, less pain when dressing, or a little more stability when standing and stepping. Making those concrete needs the goal is what brings rehabilitation closer to daily life.
JianJia Rehabilitation's Rehab Experts series will keep addressing the questions patients and families care about, sharing rehabilitation knowledge that is easy to understand and practical to refer to.
This article was prepared from the slides of this live session for general health education. It does not replace individual medical advice. Any treatment or training plan should be set by qualified clinicians after assessment.