3. Amplitude des mouvements et spasticité après un AVC

La spasticité post-AVC est caractérisée par une augmentation du tonus musculaire et des réflexes anormaux, qui peuvent avoir des incidences importantes sur les capacités fonctionnelles des membres supérieurs et inférieurs. Lorsqu’un membre supérieur est touché, la capacité à effectuer des tâches de soins personnels, comme s’habiller et manger, est réduite, ce qui peut entraîner une dépendance à l’égard des aidantes et aidants ou des membres de la famille. Les personnes présentant une spasticité d’un membre inférieur ont de la difficulté à se tenir debout, à marcher et à garder leur équilibre. La prise en charge et le traitement de la spasticité post-AVC peuvent faciliter le processus de réadaptation en allégeant le fardeau des soins et en améliorant le confort et la participation aux activités.

Si la spasticité post-AVC peut entraver la réadaptation et avoir des conséquences négatives, elle peut également présenter des avantages fonctionnels dans certains cas (p. ex. une spasticité accrue des fléchisseurs des doigts peut faciliter la préhension et une spasticité des extenseurs du genou peut aider lors d’exercices de mise en charge). L’évaluation des répercussions fonctionnelles de la spasticité et l’établissement d’objectifs de traitement clairs sont des éléments essentiels d’une prise en charge efficace de la spasticité.

Les personnes ayant subi un AVC soulignent l’importance de l’information sur la prise en charge de la spasticité pour les personnes ayant subi un AVC, leur famille et leurs aidantes et aidants. Elles notent aussi que certaines stratégies peuvent être utiles pour contribuer au soulagement et à la prise en charge. Elles soulignent les répercussions que la spasticité peut avoir sur la capacité à accomplir des exercices et des activités de la vie quotidienne. Par conséquent, il faut discuter des stratégies de prise en charge de la spasticité avec les personnes ayant subi un AVC en adoptant une approche centrée sur la personne.

Pour une évaluation et une prise en charge appropriées et en temps opportun de l’amplitude des mouvements de l’épaule, du bras et de la main, les organismes doivent optimiser les éléments suivants du système :

1. L’accès à des soins organisés pendant la période de réadaptation post-AVC, notamment des unités de réadaptation post-AVC dotées d’une équipe interdisciplinaire ayant reçu la formation appropriée et comptant le personnel nécessaire.
2. La mise en place de processus qui permettent d’accéder en temps opportun à des services de réadaptation post-AVC spécialisés et interdisciplinaires, y compris des évaluations et des traitements du type et de l’intensité indiqués.
3. L’évaluation initiale et les suivis effectués par des prestataires de soins de santé ayant l’expérience appropriée en réadaptation post-AVC tant en milieu hospitalier que dans la communauté.
4. L’expertise nécessaire au sein de l’équipe interdisciplinaire de prise en charge de l’AVC pour prévenir, prendre en charge ou améliorer le traitement de la spasticité post-AVC et pour remédier aux complications et aux limitations fonctionnelles qui y sont associées.
5. L’accès à des prestataires de soins de santé ayant une formation et une expérience appropriées dans l’évaluation, le traitement et la prise en charge de la spasticité, notamment les injections interarticulaires et les injections de toxine botulinique.
6. La mise en place de processus qui permettent d’accéder en temps opportun à des soins de réadaptation d’intensité appropriée pour les personnes ayant subi un AVC, tels qu’ils sont définis dans les Recommandations.
7. Un processus d’évaluation en temps opportun et d’accès abordable à une orthèse ou une attelle doit être envisagé pour garantir la sécurité.
8. L’optimisation des stratégies de prévention et de prise en charge de la spasticité dès le début des traitements après l’AVC et pendant les évaluations de suivi.
9. Le financement nécessaire pour les injections de dénervation chimique et les services de réadaptation post-injection connexes, le cas échéant.
10. La disponibilité des services de réadaptation de longue durée à grande échelle dans tout le continuum de soins, y compris l’accès à des établissements de soins de longue durée et de soins continus complexes, ainsi qu’à des programmes en consultation externe et en milieu communautaire.
11. L’élaboration et la mise en œuvre d’un programme d’assurance médicaments équitable et universel, déployé en partenariat avec les provinces et les territoires, et conçu pour améliorer l’accès à des médicaments à moindre coût pour toutes les personnes au pays, indépendamment de leur situation géographique, de leur âge ou de leur capacité à payer. Ce programme doit comprendre une liste étoffée de médicaments admissibles pour laquelle le payeur public est le premier payeur.

Indicateurs du système

1. Disponibilité d’une expertise et de programmes en matière de spasticité post-AVC.
2. Proportion de personnes ayant subi un AVC et présentant une spasticité post-AVC.

Indicateurs de processus

3. Intervalle entre l’apparition des symptômes de l’AVC et la première évaluation fonctionnelle incluant les signes de spasticité.
4. Fréquence et intensité du traitement de la spasticité post-AVC. 
5. Accès à des services spécialisés à l’appui de la prise en charge de la spasticité post-AVC.

Indicateurs axés sur la personne

6. Changements (amélioration) dans les scores relatifs à l’état fonctionnel selon une échelle d’évaluation uniformisée après un traitement de la spasticité post-AVC; les mesures sont réalisées 90 jours, 6 mois et 1 an après l’AVC.
7. Ampleur des changements dans les scores relatifs à la spasticité des membres supérieurs et inférieurs selon une échelle d’évaluation uniformisée (p. ex. l’échelle d’Ashworth modifiée), entre l’admission dans un programme de réadaptation en milieu hospitalier et le congé.
8. Changements en ce qui a trait aux niveaux de douleur signalés, mesurés sur une échelle d’évaluation de la douleur validée, entre les données de départ et les mesures à des périodes déterminées (p. ex. 30, 60, 90 jours après l’AVC).
9. Changements en ce qui a trait à la qualité de vie mesurés à intervalles réguliers pendant le rétablissement et la participation, puis réévalués lorsque des changements dans l’état de santé ou d’autres événements de la vie surviennent (p. ex. 60, 90 et 180 jours après l’AVC).
10. Niveaux du fardeau des soins pour la famille et les aidantes et aidants accompagnant une personne présentant une spasticité post-AVC.

Les ressources et les outils ci-dessous, qui sont externes à Cœur + AVC et aux Recommandations, peuvent être utiles à la mise en œuvre des soins de l’AVC. Cependant, leur présence ne constitue pas une approbation réelle ou implicite par l’équipe des pratiques optimales de soins de l’AVC ni par Cœur + AVC. Nous vous encourageons à examiner ces ressources et ces outils d’un œil critique et à les mettre en œuvre dans votre pratique à votre discrétion.

Renseignements destinés aux prestataires de soins de santé

• Recommandations canadiennes pour les pratiques optimales de soins de l’AVC : Module Réadaptation, rétablissement et participation communautaire après un AVC – Première partie : Planification de la réadaptation post-AVC pour la prestation de soins optimaux; et Troisième partie : Optimisation de l’activité et de la participation communautaire après un AVC, mise à jour de 2025
• Cœur + AVC. Agir pour des soins de l’AVC optimaux communautaires et de longue durée : une ressource pour les prestataires de soins de santé
• Info AVC. Mesure de l’indépendance fonctionnelle (MIF)
• Uniform Data System. Logiciel AlphaFIM® (en anglais seulement)
• Info AVC. Modified Ashworth Scale (échelle d’Ashworth modifiée)
• UF Health. Pain scales (en anglais seulement)
• Info AVC

Ressources destinées aux personnes ayant subi un AVC, à leur famille et à leurs aidantes et aidants 

• Cœur + AVC. Signes de l’AVC
• Cœur + AVC. Existe-t-il d’autres signes de l’AVC que VITE?
• Cœur + AVC. Votre cheminement après un AVC
• Cœur + AVC. Liste de vérification après un AVC
• Cœur + AVC. Infographie sur la réadaptation et le rétablissement
• Cœur + AVC. Infographie sur les transitions et la participation communautaire
• Cœur + AVC. Aide à l’autogestion après un AVC : liste de vérification pour les patients, les familles et les aidants
• Cœur + AVC. Aide-mémoire pour les soins de santé virtuels
• Cœur + AVC. Rétablissement et soutien
• Cœur + AVC. Soutien en ligne et soutien par les pairs
• Cœur + AVC. Répertoire des services et ressources
• CanStroke Essais post-AVC. Outils et ressources
• Info AVC

Evidence Table and Reference List 3a

Evidence Table and Reference List 3b

Upper extremity spasticity

Spasticity can be painful, interfere with functional recovery and hinder rehabilitation efforts. If not managed appropriately, patients may experience a loss of range of motion at involved joints of the arms, which can result in contracture. Although it is a common in clinical practice to use range-of-motion or stretching exercises and splints to prevent or treat spasticity or contracture following stroke, there is a lack of evidence supporting their benefit.  Harvey et al. ⁸² included the results of 49 RCTs in a Cochrane review including participants with neurological condition, advanced age, those with a history of trauma and those with underlying joint or muscle pathology. Of these, 11 trials included stroke cohorts treated for upper extremity impairment. Trials evaluated the effect of stretching programs (casting, splinting, self-administered, positioning, and sustained passive stretch) on preventing contractures. Stretching programs did not significantly increase joint mobility, improve spasticity, activity limitations, or pain either after the intervention or at follow-up, when compared with usual care. Salazar et al. ⁸³ included the results from three RCTs of patients post stroke with upper extremity spasticity and reported that static stretching with positioning orthoses was associated with significantly greater reduction in wrist-flexor spasticity compared with no therapy or conventional physiotherapy (mean difference [MD]= -1.89, 95% CI -2.44 to -1.34).

While it is well-established that treatment with Botulinum toxin–type A (BTX-A) reduces focal spasticity in the finger, wrist and elbow, it remains uncertain whether there is also improvement in upper extremity function. In the BOTOX® Economic Spasticity Trial (BEST), 273 persons with chronic post-stroke upper and lower extremity spasticity were randomized to receive a single dose of BTX-A with an optional second dose offered ≥ 12 weeks after the first injection, or placebo in addition to usual care. Dosing and site of injection was based on clinician judgement. In the publication of the trial that was dedicated to functional outcomes, ⁸⁴ there were no significant differences between groups at weeks 12, 24 or 52 with respect to the percentage of patients who achieved their principal active functional goal (33.1% vs. 28.9%, 40.9% vs. 33.3% and 45.0% vs. 52.4%, respectively), although a higher number of persons in the BTX-A groups achieved their secondary passive functional goals at 24 weeks, (60.6% vs. 38.6%, p=0.016), but not at weeks 12 or 52. In another BEST publication, BTX-A was more effective than placebo in reducing pain from baseline to week 12. ⁸⁵ Higher proportions of patients with pain in the BTX-A group achieved ≥30% and ≥50% reductions in pain. Shaw et al. ⁸⁶ randomized 333 subjects < 1 month following stroke with spasticity of the elbow (modified Ashworth Score [MAS] >2) and/or spasticity of the shoulder, wrist or hand with reduced arm function to receive 100 or 200 U Dysport ® in addition to a standardized therapy program provided for one hour/day, 2x/week for 4 weeks) or therapy program only. Repeat injections were available to participants in the intervention group at 3, 6 and 9 months. There was no significant difference in the percentage of patients who had achieved a successful outcome (defined by 3 different levels of improvement on the Action Research Arm Test, depending on baseline arm function) at one month following treatment: 25% of patients in the treatment group compared with 19.5% of patients in the control group (p=0.232). However, significant differences in favor of the intervention group were seen in muscle tone at 1 month; upper extremity strength at 3 months; basic arm functional tasks (hand hygiene, facilitation of dressing) at 1, 3, and 12 months, and pain at 12 months. McCrory et al. ⁸⁷ reported there were no significant between group differences in Assessment of Quality-of-Life scale change scores, pain, mood, disability or carer burden at 20 weeks in 102 patients with moderate to severe spasticity of the arm, who received 750-1,000 U Dysport ® or placebo an average of 6 years following stroke. In a systematic review, Sun et al. ⁸⁸ pooled the results from 18 RCTs of adults with upper extremity spasticity following stroke in which a wide variety of outcomes were reported. Trials compared one-time injections of BTX-A formulation with placebo. At 4 to 16 weeks, treatment with BTX-A was associated with significant improvement in muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55), physician global assessment ([SMD=0.51; 95% CI 0.35-0.67) and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20), with no significant improvement on active upper extremity function (SMD=0.49; 95% CI -0.08 to 1.07). BTX-A may also be used in addition with other treatment modalities to reduce spasticity. Other treatments include electrical stimulation, ^{89, 90} constraint-induced movement therapy,⁹¹ taping, ⁹² and dynamic splinting. ⁹³

In cases where spasticity is generalized, and it would be impractical, or contrary to patients’ wishes to inject multiple muscle groups with BTX-A, the use of oral agents may be considered as an alternative treatment. Traditional pharmacotherapies for spasticity include centrally acting depressants (baclofen and tizanidine) and muscle relaxants; (dantrolene) however; these treatments are only partially effective in treating spasticity and have the negative side effects of weakness and sedation. Treatment with oral baclofen has not been well studied in the stroke population and is used more frequently in patients recovering from spinal cord injury; however, in one small RCT, Güntürk et al. ⁹⁴ reported that in patents randomized to receive treatment with BTX-A (total dose 100-300 U) or oral baclofen (total dose 3-80 mg daily), median elbow, wrist and finger MAS scores and pain scores had improved significantly at 6 weeks in both groups, with no significant differences between groups. There was no significant improvement in median Barthel Index scores within, or between groups at 6 weeks. Tizanidine has been well-studied in other conditions including multiple sclerosis and acquired brain injury and has a better side effect profile than other oral agents.  There is only a single open-label trial of the use of tizanidine post stroke. ⁹⁵ Following 16 weeks of treatment in which 47 patients received a maximum daily dose of 36 mg (mean 20 mg), there was a decrease in mean combined total MAS scores (9.3 vs. 6.5, p=0.038). There were also significant improvements in pain, quality of life, and physician assessment of disability. 

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment that uses acoustic shock waves to reduce pain and heal tissue and has been used traditionally to treat injuries such as tendonitis, and other soft tissue injuries, but has also been used for the treatment of spasticity following stroke. Cabanas-Valdés et al. 96 included the results of 16 RCTs, including 764 participants who had sustained an ischemic or hemorrhagic stroke and had residual upper-extremity hemiparesis and spasticity. In most trials, ESWT plus conventional therapy was compared with conventional therapy only. A sham condition was used in two trials. ESWT was associated with a significant reduction in MAS and pain scores compared with therapy alone, and an improvement in Fugl-Meyer Assessment scores. 

Non-invasive brain stimulation using either transcranial direct-current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) has been shown to be beneficial for the treatment of upper-extremity spasticity. rTMS and tDSC were associated with significant reductions in mean MAS scores compared with the control condition (sham stimulation, +/- cointerventions) in a systematic review authored by Wang et al ⁹⁷ (MD= −0.40, 95% CI −0.56 to −0.25 and MD=−0.65, 95% CI −1.07 to −0.22, respectfully), including the results of 14 RCTs of 236 patients with upper extremity spasticity.

Lower Extremity Spasticity

Few studies have been published examining the prevention or treatment of spasticity or contracture using antispastic pattern positioning, range of motion exercises, stretching and/or splinting in the lower extremity. Chen et al. ⁹⁸ randomized 121 patients discharged from inpatient rehabilitation, an average of 3.3 months post stroke, with lower extremity spasticity to a nurse-guided home-based rehabilitation exercise program, aimed at reducing spasticity and improving mobility, which lasted for 12 months, or to receive conventional rehabilitation. At the end of 12 months, there was significantly greater improvement in mean lower extremity MAS scores, as well as motor function, gait speed and BI scores in the home-based rehabilitation exercise program group (from 3.32 to 1.07 vs. 3.27 to 1.69, p for group x time interaction =0.004). Kluding et al. ⁹⁹ reported that 8 sessions of functional task practice combined with ankle joint mobilizations, provided over four weeks, resulted in increased ankle range of motion, compared with a group that received therapy only, in the chronic stage of stroke. The participants in the intervention group gained 5.7 degrees in passive ankle range of motion compared with 0.2 degrees in the control group (p<0.01). 

The use of BTX-A for treatment of lower extremity spasticity is not as well-studied compared with the upper extremity. In the REFLEX Study, Wein et al. ¹⁰⁰, included 468 patients, recruited from 60 centres in the United States with spasticity of the ankle (MAS ≥3) following stroke of duration >3 months. Participants were randomized to receive either BTX-A (Botox® 300–400 U) or placebo and followed for 12 weeks during the double-blind phase of the trial. During this phase of the trial there was significantly greater improvement in mean MAS ankle scores from baseline to 4-6 weeks in the BTX-A group (-0.81 vs. -0.61, Δ= -0.20). During the open-label phase of the trial, mean MAS scores were reduced by -1.2 points for patients in the BTX-A group and by -1.4 points for those in the group that initially received placebo. During the double-blind phase, the mean Physician-assessed Clinical Global Impression of Change (CGI) from baseline to 4-6 weeks was significantly greater in the BTX-A group (0.86 vs. 0.65; Δ=0.22). At the end of the open-label phase, patients in both groups had improved to an average of 1.6 points. Goal Attainment Scale (GAS) scores, reflecting individualized patient goals, showed incremental improvements with each subsequent treatment cycle.

A systematic review by Doan et al. v101 included the results of 12 RCTs of patients with lower extremity spasticity. Duration of stroke was greater than three months in 8 trials. Patients were randomized to receive BTX-A injections or placebo. At four weeks, there was significantly greater improvement in measures of spasticity (Ashworth Scale [AS], MAS) in the BTX-A group (SMD=-0.61, 95% CI -0.92 to -0.3). Kaji et al. ¹⁰² randomized 120 patients with lower extremity spasticity following a stroke of greater than 6 months post onset to receive a single treatment of 300 U Botox® or placebo. There was a significantly greater reduction in mean MAS scores at weeks four, 6 and 8 in the treatment group compared with the control group; however, there were no significant differences between groups at week 10 or 12. Pittock et al. v103 compared escalating doses of BTX-A with placebo and found that the highest dose (1,500 U Dysport ®) was associated with the greatest relief of calf spasticity compared with placebo at four, 8 and 12 weeks following treatment. Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity by week four only. 

Intrathecal baclofen (ITB) is not generally used in the treatment of post-stroke spasticity, but can be considered in certain cases, particularly if other treatment options are ineffective or if the spasticity is severe and disabling. It is used more commonly in spinal cord injury, multiple sclerosis and cerebral palsy. The Spasticity In Stroke–Randomized Study’ (SISTERS) ¹⁰⁴ included 60 patients recruited from 11 rehabilitation centres in Europe and the US with chronic stroke with spasticity in ≥2 extremities and an AS score ≥3 in at least two affected muscle groups in the lower extremities. After a run-in period, patients were randomized to receive ITB or conventional medical management, using a combination of oral antispastic medications, comprising at least one of oral baclofen, tizanidine, diazepam (or other benzodiazepines), or dantrolene. At 6 months post treatment, the mean reduction in lower extremity AS scores was significantly greater in the ITB group (-0.99 vs. -0.43, p=0.0140). 

Less conventional treatments for the treatment of lower extremity spasticity include extracorporeal shock wave therapy (ESWT) and whole-body vibration (WBV), although both are considered a complementary therapy, and are used in addition to traditional rehabilitation therapies. In two small RCTs, ESWT was associated with significantly greater reductions in spasticity compared with conventional therapy. ^{105, 106} In a systematic review including 11 RCTs, Zhang et al. ⁷⁶ reported that WBV was associated with a significant reduction in lower extremity spasticity (SMD= −0.26, 95% CI −0.44 to −0.07). Treatment was most effective in the acute/subacute stage of stroke and in patients under 60 years. 

Sex & Gender Considerations

Current research suggests there are no significant sex differences in the development of upper or lower extremity spasticity following a stroke. None of the studies we reviewed that examined any interventions for post-stroke spasticity included an analysis that explored sex or gender as a potential determinant of rehabilitation outcome.