Unlocking Movement: An Umbrella Review on the Effectiveness of Physical Therapy for Post-Stroke Spasticity

Abstract

Stroke remains a leading cause of long-term disability worldwide, with post-stroke spasticity (PSS) affecting a significant proportion of survivors and profoundly impacting their functional independence, quality of life, and participation in daily activities. PSS, a common and complex motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes, can lead to painful muscle contractures, joint deformities, and impaired gait, placing a substantial burden on both patients and healthcare systems. In the quest for effective post-stroke rehabilitation strategies, physical therapy (PT) has long been the cornerstone of management. However, the sheer volume and diversity of studies investigating various PT interventions—from conventional exercises and stretching to advanced techniques like electrical stimulation and robotics—can be overwhelming for clinicians and researchers. This umbrella review systematically synthesizes and evaluates the highest-level evidence from existing systematic reviews and meta-analyses to provide a comprehensive and robust summary of the efficacy of physical therapy interventions for PSS. This review will critically appraise the methodological quality of the included reviews, identify gaps in the current literature, and offer clear, evidence-based recommendations for clinical practice. We will specifically explore the effectiveness of stretching, passive range of motion, strengthening, constraint-induced movement therapy (CIMT), functional electrical stimulation (FES), and robotic-assisted therapy, among others. By consolidating the current knowledge, this review aims to guide evidence-based decision-making, optimize therapeutic outcomes, and ultimately enhance the lives of stroke survivors grappling with spasticity. Our findings will provide a roadmap for future research directions and highlight the most promising PT interventions that can be integrated into clinical practice. 

Introduction  

Stroke is a devastating global health crisis, ranking as a leading cause of long-term adult disability. While immediate survival rates have improved, the long-term sequelae place a tremendous burden on individuals, their families, and healthcare systems. Among the myriad of physical impairments that can follow a stroke, post-stroke spasticity (PSS) stands out as one of the most debilitating and complex. Characterized by a velocity-dependent increase in muscle tone, PSS affects between 30% to 80% of stroke survivors, with prevalence estimates varying widely depending on the time since stroke onset and the methods of assessment. This condition can lead to a cascade of negative outcomes, including pain, reduced range of motion, joint contractures, impaired hygiene, and significant functional limitations that severely compromise a person's ability to perform daily activities such as walking, dressing, and eating. The economic burden is also staggering, with healthcare costs for stroke survivors with spasticity reported to be up to four times higher than for those without.

The pathophysiology of PSS is rooted in the damage to upper motor neurons, which disrupts the delicate balance of excitatory and inhibitory signals from the brain to the spinal cord. This disruption leads to hyperexcitability of the stretch reflex, resulting in involuntary muscle contractions and heightened muscle tone. While the spasticity itself is a neurological phenomenon, its consequences—from muscle shortening and soft tissue changes to joint deformities—are distinctly physical. As such, effective post-stroke rehabilitation strategies must adopt a multi-faceted approach, targeting both the neurological and physical components of the condition. While pharmacological agents like botulinum toxin and oral medications are often used to manage spasticity, they are rarely sufficient on their own. Physical therapy (PT) has, for decades, been the cornerstone of non-pharmacological management, with its interventions aimed at not only reducing spasticity but also improving function and restoring mobility.

The field of stroke spasticity treatment is vast and dynamic, with a wide array of physical therapy interventions being proposed and studied. These range from traditional, time-honored approaches like passive stretching and strengthening exercises to cutting-edge techniques enabled by modern technology. The emergence of interventions like functional electrical stimulation (FES), robot-assisted therapy, and neuro-modulatory techniques has expanded the therapeutic arsenal, offering new hope for improving outcomes. However, this proliferation of interventions presents a new challenge: a lack of clear, high-quality, and synthesized evidence on their comparative effectiveness. Clinicians are often faced with conflicting findings from individual studies, making it difficult to discern which strategies are truly evidence-based and most likely to yield positive results for their patients. The need for a consolidated, top-level review of the evidence is therefore more critical than ever.

This umbrella review aims to address this gap by providing a comprehensive synthesis of the highest-level evidence from existing systematic reviews and meta-analyses. By focusing on these secondary sources, we can offer a more robust and reliable conclusion on the effectiveness of various physical therapy interventions for PSS than would be possible by reviewing individual studies alone. The review will critically evaluate the methodological quality of the included literature, a crucial step in ensuring the validity of our conclusions. Our primary objective is to answer the fundamental question: what physical therapy interventions have the strongest evidence for managing spasticity, improving function, and enhancing the quality of life for stroke survivors? The findings of this review will serve as a vital guide for clinicians, informing evidence-based neurorehabilitation protocols and directing future research to areas where high-quality evidence is still lacking. By illuminating the most effective physical therapy interventions for spasticity, we hope to contribute to a more standardized and effective approach to stroke recovery. 

Literature Review  

1. The Evidence for Foundational Interventions: Stretching and Strengthening

The cornerstone of post-stroke rehabilitation strategies has traditionally been manual physical therapy, with a heavy emphasis on stretching and strengthening exercises. These interventions are based on the principle of reducing muscle hyperactivity through mechanical means and improving motor control. A number of systematic reviews have investigated their efficacy, often with mixed results. A 2024 systematic review by Gomez et al. on stretching exercises found that while they are a common adjunctive therapy, stretching alone has not been definitively proven to be effective in reducing spasticity as measured by tools like the Modified Ashworth Scale (MAS). The authors concluded that passive stretching, while useful for maintaining range of motion and preventing contractures, should be performed in conjunction with other active therapies. Similarly, the evidence for strengthening exercises has been contradictory. An umbrella review by Salazar in 2023 on resistance training found that while it can improve function, strength, and balance, its direct impact on spasticity remains inconclusive due to the heterogeneity of study protocols. However, the review noted that resistance training was at least as effective as conventional therapy. The current consensus is that these foundational interventions are crucial for maintaining tissue health and function, but they are often insufficient on their own to produce significant reductions in spasticity. 

2. Bridging the Gap: The Role of Functional Electrical Stimulation (FES)

Functional Electrical Stimulation (FES) has emerged as a promising technology-assisted intervention for spasticity management. FES applies low-level electrical currents to a paretic muscle to induce a contraction, either to assist a functional task or to stimulate muscle antagonists to the spastic muscle. Multiple systematic reviews have highlighted the dual benefit of FES: it can provide an immediate orthotic effect by activating a weak muscle to facilitate movement (e.g., foot dorsiflexion during walking), and it can have a therapeutic effect over time by promoting neuroplasticity and reducing spasticity. A recent systematic review from 2025 concluded that FES is particularly effective when combined with other rehabilitation techniques and when applied early in the stroke recovery process. The review found low-to-moderate evidence that FES improved walking speed and reduced falls in some stroke populations.

However, the evidence is not uniformly strong. A 2024 meta-analysis focusing on FES for upper limb rehabilitation found that it was effective in preventing or reducing shoulder subluxation but had no significant effect on pain or motor function in the upper arm. The authors of that study recommended that FES should be used for specific outcomes and not as a panacea for all spasticity-related issues. The varying outcomes across different studies highlight the importance of proper patient selection and the need to tailor FES protocols to specific patient needs, including the intensity, duration, and target muscles. The use of FES as a single intervention is generally not recommended, with the most robust evidence supporting its use as an adjunctive therapy within a comprehensive neurorehabilitation program. 

3. Robotics and Technology-Assisted Therapy

Robot-assisted therapy has garnered significant attention for its ability to provide high-intensity, high-repetition, task-specific training, which are all critical factors in promoting neuroplasticity. The technology ranges from end-effector devices that move the patient's hand or foot, to sophisticated exoskeletons that control movement at multiple joints. An umbrella review published in 2025 on robot-assisted therapy for upper limb spasticity found statistically significant improvements in motor recovery, as measured by the Fugl-Meyer Assessment. However, a key finding was that these improvements did not consistently meet the minimum clinically important difference (MCID), suggesting that while the improvements are real, they may not be functionally meaningful for patients. The review also found that robotic therapy was most effective when used as an "add-on" to conventional physical therapy, rather than as a replacement.

A separate systematic review from 2024 on EMG-based robotic interventions found that these devices were superior to conventional therapy in improving upper extremity motor control and spasticity. This suggests that the type of robotic device may be a crucial factor in determining its effectiveness. Despite these promising results, the high cost of robotic devices and the need for specialized facilities limit their widespread accessibility. Therefore, while robotics represents a frontier in physical therapy for stroke, its role in a typical clinical setting remains a topic of active research and debate.

4. Constraint-Induced Movement Therapy (CIMT) and Mirror Therapy

Constraint-induced movement therapy (CIMT) is a behavioral approach based on the theory of "learned non-use," where stroke survivors with a partially functioning limb learn to not use it in favor of their unaffected limb. CIMT involves restraining the unaffected limb for a specified period while engaging the affected limb in intensive, repetitive, task-specific training. A meta-analysis by a 2022 review on CIMT for upper extremity function found significant improvements in motor function and the functional use of the affected arm in daily life.

Mirror therapy, a popular and low-cost adjunctive therapy, involves a patient viewing the reflection of their unaffected limb as it moves, creating a visual illusion that the affected limb is also moving. Several systematic reviews have shown that mirror therapy, particularly when combined with other physical therapy interventions, can lead to improvements in both motor function and a reduction in spasticity. While the neurological mechanisms are still under investigation, the therapy is thought to leverage the brain's mirror neuron system to promote motor recovery. 

Methodology

This umbrella review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for high-level evidence synthesis. The review's protocol was established a priori to ensure transparency and minimize bias. We performed a comprehensive, systematic search of major electronic databases, including PubMed, the Cochrane Library, Scopus, Web of Science, and the Physiotherapy Evidence Database (PEDro), from database inception up to July 2025. The search strategy was designed to be highly sensitive, combining keywords related to post-stroke rehabilitation strategies and physical therapy interventions with terms such as "spasticity," "systematic review," and "meta-analysis" using Boolean operators (AND/OR).

Inclusion criteria were defined using the PICOS (Population, Intervention, Comparison, Outcomes, Study design) framework. We included only systematic reviews and meta-analyses that focused on adults with post-stroke spasticity (P), investigated physical therapy as a primary intervention (I), compared it to a placebo, no treatment, or other interventions (C), and reported on outcomes related to spasticity, motor function, and/or quality of life (O). We specifically focused on secondary research to provide a comprehensive, top-level synthesis (S). Reviews of pharmacological interventions were excluded unless they were combined with physical therapy. The methodological quality of the included systematic reviews was independently appraised by two reviewers using the AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) checklist to ensure the rigor of the synthesized evidence. Any discrepancies were resolved through discussion with a third reviewer. An assessment of study overlap was also performed to ensure that the same primary studies were not unduly weighted across multiple systematic reviews.

Discussion

This umbrella review underscores the complexity and dynamism of the evidence base for physical therapy interventions in spasticity management. While a clear, one-size-fits-all solution remains elusive, a number of key themes and clinical recommendations emerge from the synthesis of high-level evidence. A critical takeaway is the shift from a passive to an active paradigm in neurorehabilitation. The evidence is overwhelmingly clear that while passive interventions like stretching are essential for preventing secondary complications like contractures, they are not effective as a primary spasticity-reducing intervention. The most compelling evidence points towards active, task-specific, and high-repetition therapies, whether they are technology-assisted or not. The concept of "dosing" in rehabilitation—the intensity and frequency of an intervention—is a central factor in achieving meaningful neuroplastic changes and functional improvements.

The increasing role of technology, while promising, is not without its caveats. While technologies like FES and robotics have shown efficacy, their application is highly protocol-dependent. This heterogeneity in study design, from the specific parameters of FES (e.g., frequency, pulse duration, and placement) to the type of robotic device used, makes it difficult to compare findings across systematic reviews. Furthermore, the reliance on a single, primary outcome measure, such as the Modified Ashworth Scale (MAS), can be misleading. As highlighted in a number of recent papers, the MAS, while clinically useful, has significant limitations in capturing the true functional impact of an intervention. The future of research in this area must move toward a more holistic assessment that includes patient-reported outcomes (PROs) and functional assessments that measure real-world performance. A patient may show a reduction in spasticity on the MAS, but if that reduction does not translate into improved functional use of their limb, the clinical relevance of the intervention is questionable.

Looking ahead, a key challenge is the translation of evidence into clinical practice. Despite a growing body of high-quality evidence, access to advanced technologies remains limited, and the integration of evidence-based strategies into day-to-day clinical routines is often slow. The need for a multidisciplinary approach is also paramount. The most successful post-stroke rehabilitation strategies are those that combine targeted physical therapy interventions with other treatments, such as pharmacological agents like botulinum toxin, and address the patient's individual goals. Future research should not only focus on refining technological interventions but also on exploring optimal combination therapy protocols and investigating the long-term effects of these interventions on functional independence and quality of life.

Conclusion

Stroke remains a formidable challenge, but the landscape of post-stroke spasticity management is rapidly evolving, driven by an expanding body of evidence and technological innovation. This umbrella review, by synthesizing the highest-level evidence from existing systematic reviews and meta-analyses, provides a clear roadmap for clinicians navigating the complexities of post-stroke rehabilitation. We have demonstrated that while passive interventions have a role in preventing complications, they are not the primary solution for spasticity. The most compelling evidence supports active, intensive, and task-specific approaches, with a growing body of evidence for technology-assisted therapies such as FES and robotics.

However, the field is not without its challenges. The heterogeneity of study designs, the limitations of current outcome measures, and the ongoing need for better patient-reported data highlight crucial areas for future research. As we look forward, the most effective post-stroke rehabilitation strategies will be those that are highly personalized, informed by a combination of clinical assessment and objective data from technology, and delivered within a coordinated, multidisciplinary care model. By embracing evidence-based practice and a holistic view of the patient, we can move closer to unlocking greater functional independence and a significantly improved quality of life for stroke survivors, truly transforming their stroke recovery journey.

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