“Spasticity: The Complication That Amplifies Disability After Stroke”

The most frequent type of stroke—accounting for approximately 85% of cases—is caused by a blood clot obstructing or impairing blood (and thus oxygen and nutrient) flow to the brain (ischemic stroke). The remaining ~15% are attributable to rupture of cerebral blood vessels, leading to hemorrhagic stroke. Without oxygen and nutrients, neuronal death occurs rapidly. Consequently, body parts controlled by those neurons may malfunction, potentially causing permanent disability. Early diagnosis and treatment are crucial for managing disability and improving quality of life.

Complications and Consequences of Stroke

• The main consequence of stroke is disability.

• About one-third of stroke survivors remain dependent on others for self-care even one year later.

• Stroke is the leading cause of neurological disability in developed countries and the second leading cause of dementia.

• Among stroke complications, spasticity plays a central role.

Spasticity is the continuous involuntary contraction of muscle groups in the upper or lower limbs resulting from central nervous system damage. Many stroke survivors develop spasticity, which severely impairs mobility, generates pain, complicates daily hygiene, and can lead to injury due to uncontrolled movements. It also significantly hinders participation in rehabilitation programs.

Rehabilitation After Stroke with Spasticity

Post-stroke rehabilitation aims to help patients preserve or regain mobility to maintain or enhance their functional independence in activities of daily living (ADLs)—walking, speech, personal hygiene, dressing, eating, toileting—as well as more complex tasks such as household chores, phone use, and driving.

Botulinum Toxin in Spasticity

In recent years, botulinum toxin injections have been administered to spastic patients to produce localized muscle relaxation, thereby reducing pain and facilitating physical therapy—leading to overall improvement in quality of life and functional performance.

Key points:

• Best results occur when botulinum toxin is applied early, at the first sign of emerging spasticity, and as part of a comprehensive rehabilitation program.

• In chronic cases with established contractures, botulinum toxin mainly relieves pain, with little effect on functional improvement.

Advantages of botulinum toxin use:

• Simple administration with minimal preparation

• Minimal, transient side effects when dosed correctly

• Enables reduction or discontinuation of systemic muscle relaxants, which often cause fatigue, sedation, and gastrointestinal issues

• Injection is targeted to hyperactive muscles—no systemic effects

• Proven reduction in spasticity, enhancement of rehabilitation outcomes, especially in physiotherapy and occupational therapy

Mechanism:

• Botulinum toxin blocks neurotransmitter release at the neuromuscular junction, causing localized, temporary, and dose-dependent muscle relaxation

• Injected nearly painlessly via a fine electrode needle, guided by electromyography (EMG)

• Should be administered by a specialist physician familiar with anatomy and injection technique

• Effects appear within a few days, lasting 3–4 months, and in some cases up to 6 months—hence repeat injections are needed at intervals

• Early intervention yields better outcomes

Insurance coverage in Greece:

• Covered for medical conditions like dystonia or post-stroke spasticity, not for cosmetic reasons

Botulinum toxin is widely used in conditions with excessive muscular activity—e.g., blepharospasm, cervical dystonia, writer’s cramp, hemifacial spasm, axillary hyperhidrosis, spasticity in children (>2 years) with cerebral palsy, and adult post-stroke spasticity. Its use has recently expanded into chronic headaches and neurogenic bladder management with encouraging results.

Although potent, the doses used are so low that no harmful effects occur. Millions worldwide have benefited with minimal adverse effects from previously challenging problems.

Optimal administration: by specialized clinicians using multidisciplinary support, including physiotherapy, occupational therapy, orthotic intervention, and patient education.

Where Is Botulinum Toxin–Based Spasticity Management Provided?

• Specialized Spasticity Clinics operate within public rehabilitation hospitals in the Attica region and certain state neurological clinics.

• A dedicated Spasticity Clinic also exists at the Apollonios Rehabilitation Center, where treatment is embedded within a multidisciplinary rehabilitation program.

• Botulinum toxin injections are administered by a specialist physiatrist or neurologist, under EMG guidance, to maximize outcomes.

• Patients receive education on managing spasticity and related impairments to improve their quality of life.