The Effects Of A Stroke: Tonicity and Spasticity In The Extremities

The Effects of Stroke on Tonicity & Spasticity in the Extremities

Written by Jessica Dietz, PT, DPT, NCS

According to the American Heart Association, someone in the United States has a stroke every 40 seconds. Stroke continues to be the leading cause of serious long-term disability in the United States. However, up to 80% of strokes can be prevented by lifestyle changes (especially exercise!) and management of atrial fibrillation, diabetes, high blood pressure and cholesterol.

There are two different types of stroke– ischemic and hemorrhagic.
Ischemic strokes: are the most common type of stroke and also the most preventable. Ischemic strokes occur due to disruption of blood flow to the brain, such as narrowing/blocked arteries or blood clots.
Hemorrhagic strokes: are less common and due to a blood vessel break or bleed in the brain like an aneurysm. For more information about types of strokes, visit the American Stroke Association.

Depending on the location, severity, and several other risk factors, every person with a stroke is different! There are many possible changes someone may experience after a stroke such as:

  • Weakness
  • Difficulty speaking or swallowing,
  • Numbness
  • Altered cognition
  • Vision changes
  • Difficulties with balance

Only about 10% of patients experience a full recovery after having a stroke. That means almost 90% have some type of mild to severe impairment that may continue to require rehabilitation or medical management.

One common as well as frustrating and potentially debilitating symptom after a stroke is “TONE and/or SPASTICITY”. Throughout this blog, we will discuss more about tone/spasticity and its management and treatment.

What Is Tone/Spasticity?

Your doctors may have used the terms “tone” or “spasticity” to describe the stiffness in your extremities. Although tone and/or spasticity can be found in the neck and trunk it more commonly occurs in the extremities after a stroke. Often times these two terms are used interchangeable, however, they are different so it is important to know the difference as they are managed differently. To make it even more complicated, sometimes you can have both!

Everyone has some degree of TONE, which is the body’s underlying resting resistance to movement or stretch. Think, if you have low tone (i.e. hypotonicity) your limbs would be very easy to move almost like an overcooked noodle. More commonly, we see too much tone (i.e. hypertonicity) which causes a stiffness and resistance to movement.

SPASTICITY, however, is the body’s resistance to quick movements caused by a quick stretch to the muscle. For example, a quick stretch to your calf muscle when you are sitting can create clonus (which is a type of spasticity) that causes a fast beating motion of your leg. Spasticity is different than just muscle spasms as spasms often occur randomly and without a stretch of the muscle.

Why Does Tone/Spasticity Matter?

Normally with movement or stretch to the muscle, there would be a normal resistance in contrast to that movement or stretch. However, after a stroke there is often a loss of normal inhibition from the brain which can lead to over-excited neurons and nerve tracts. Hypertonicity and spasticity can further lead to postural changes, contractures (i.e. permanent loss of a joint’s range of motion), balance difficulties, and pain.
Here are two examples of condition presentations and how they impact function.

Example #1 – Hypertonicity in arm/hand
One of the most common presentations is hypertonicity in the affected arm and hand. This can cause the arm to remain stiff and difficult to move for getting dressed or performing other daily activities. Hypertonicity in the hand can cause the hand to remain in more of a clenched, fisted position which makes fine motor tasks difficult, such as grabbing a utensil to eat. This is also a common example of how an affected limb can be stiff (due to tone), weak, and potentially painful.

Example #2 – Spasticity in leg
Another presentation can be spasticity in the quadriceps muscle. The quad muscle is one of the most important muscles for standing and walking. If this muscle becomes spastic after a stroke it can lead to hyperextension of the knee or “stiff leg” when trying to take a step or go upstairs. This is a good example of also the phenomenon that spastic muscles are often WEAK muscles and sometimes you can use your spasticity for function. But if you take too much medication that decreases your spasticity you may find it more difficult to stand or walk.

How To Manage Tone/Spasticity?

Often the first treatment for both tone and spasticity include medication. Some common medications include: Baclofen (lioresal), Clonazepam (klonopin), Dantrolene (dantrium), Iazepam (valium), and Tizanidine (Zanaflex).

Other treatments for higher levels of tone/spasticity are botox injections, phenol/alcohol injections, and intrathecal baclofen pump. These medications should be managed and monitored by your doctor for the appropriate dose to minimize side effects of high doses.

Physical therapy and exercise provide conservative and non-medical management of either tone and/or spasticity. Physical therapy can help the most in the following ways:

Optimize the “window of opportunity” that exists with any of the above medications or injections that are used. For example, botox injections are most effective within 3-90 days after the procedure. This means we may have more range of motion, less resistance to movement, or less pain that our therapeutic interventions may be more effective.
Optimize function despite having tone or spasticity. Despite medication and other management, there usually is some level of abnormal tone or spasticity present which means you have to learn how to move and safely function with this new tone/spasticity. There are many “tricks of the trade” and techniques that a physical therapist can recommend to help maintain independence and function.
Skilled observer of function and movement. Often times, physical therapists and doctors work together in order to find the appropriate dosage of medication as well as muscle groups for injections that will allow someone to be the most mobile and independent.

Some other non-medical treatment ideas that can be performed in therapy include vibration, electrical stimulation (e-stim), taping, orthotics or bracing, and other adaptive devices.

The most successful treatment although continues to be specific stretching and strengthening, so see your local physical therapist for specific stretches and strengthening exercises to make it individualized to you!

How To Prevent A Stroke

We could not have a blog about stroke without highlighting the importance of stroke prevention! Once again, 80% of strokes can be prevented. Some of the most important prevention recommendations include some of the following:

  • Exercising/moving more
  • Eating healthy
  • Maintaining a healthy body weight
  • Quitting smoking
  • Decreasing alcohol consumption
  • Having regular doctor visits

To read more information about more prevention tips, visit the following websites:
National Stroke Association
American Stroke Association

Concussion Treatment: More Than Just Getting “Your Bell Rung”


According to the CDC, 2.87 million TBI-related emergency department (ED) visits, hospitalizations, and deaths occurred in the United States in 2014. Concussions are considered a type of mild Traumatic Brain Injury (TBI); while there is no structural damage, there is a temporary chemical imbalance/flux . The CDC further describes concussions as “any bump, blow, or jolt to the brain or body that causes the head and brain to move rapidly back and forth”. Common causes of concussions include the following: sports and recreation, falls especially with elderly population, car accidents, and military blasts/blunt trauma.

Breaking the Concussion Myth

The common misconception with concussions is that they are not a “big deal” and someone can return-to-game, work, or combat/service without taking the necessary steps to help relieve post-concussion symptoms. During the first 24 hours, it is most important to eliminate the potential risk of a second concussion. The brain is at a highly vulnerable for what we call “Second Impact Syndrome” which can cause further – and more[JD3]  severe – brain injury and potentially even life threatening. Multiple concussions can also cause more and more symptoms and prolong recovery.

Concussions are not just “your bell got rung”! We need to encourage athletes, military, and the community to listen to their bodies, and if they suspect a concussion speak up and take action. Managing your concussion symptoms may be able to return[JD4]  to activity sooner and drastically reduce their time needed to recover as well as reduce the likelihood of having chronic symptoms.

What to Do Immediately After a Concussion

Immediately after a concussion, your brain goes through a flux of chemical imbalances that are at its peak for the first 24 hours and can last up to 7-10 days post-concussion. During this time, someone may experience any of the following symptoms:

Physical/Postural Cognitive
Emotional Sleep
-Light sensitivity
-Eye problems
-General unsteadiness
-Feeling dazed
-Mentally “foggy”
-Feeling slowed down
-Answer questions slowly
-Difficulty concentrating
-Repeats self
-Drop in academic performance
-Personality changes
-More/less emotional
-Sleeping more/less
-Difficulty falling asleep or staying asleep


With current research, complete mental and physical rest is recommended for the first 24-48 hours after a concussion. During this time, it is very important that an athlete not return to play until cleared by a medical provider! After 48 hours, someone can gradually re-engage back into their normal daily activities. It is recommended to schedule half days when returning to work or school as well as allowing breaks as needed throughout the day. In order to manage symptoms and avoid the snowball effect, use the “Rule of 3’s”. This means stopping any activity that is increasing symptoms >3 points from your “baseline” (on healthcare’s 0-10 scale).

When to Seek Further Concussion Treatment

Someone should seek emergency medical care if they suspect skull fractures, potential spinal cord injury, significant loss of consciousness, worsening mental status, seizures, or persistent vomiting. Even have a family member or friend help monitor things! Medical doctors should be the primary team member to manage and follow-up regarding “return to play”, “return to work”, and “return to learn/school” considerations.

Typically, we recommend pursuing Physical Therapy, specifically concussion-based rehabilitation, after  ~1 month of persistent symptoms. Physical Therapy can help with headache management, dizziness/unsteadiness, light/noise sensitivity, eye problems, visual over-stimulation, and coordination/processing speed. It is recommended to find a Physical Therapist in the area that is knowledgeable and has experience with concussion rehabilitation. These types of experienced therapists will be able to make an individualized concussion treatment plan that are specific and directed toward the patient’s goals. Post-concussion rehab can last anywhere from 1 month to > 6 months.

Other team members may include neuro-psychologists who perform neuro-cognitive screening and assessment, ophthalmologist for continued eye problems, speech therapy for continued cognitive deficits, athletic trainers to help assist return to play, and teachers/coaches/employers  to construct appropriately paced return to activity.



Get To Know Your Physical Therapist Assistant – Erin Mumby, PTA

Therapydia Denver physical therapist assistant Erin Mumby, PTA, takes some time to talk about her own experience with injury, why she loves Colorado, and her continuing education focus on pelvic floor for male and female patients.

When did you know that you wanted to be a physical therapist assistant?

I was always active and knew I wanted a profession which would nurture this part of me. I injured my knee and hip during varsity cross country and received PT which started me down this path.

What’s your favorite song to get you motivated?

Morning Sun. It’s very repetitive but I love it.

What is the biggest challenge involved in being a PTA?

Being a PTA has a few unique challenges. PTA’s have to be able to form their own personalized treatment style while at the same time, learn each PT’s treatment style to maintain congruency with pt treatment plans. We also face the issue of patients thinking we have no formal education. So patient education is important for us to gain trust.

How do you like to stay active?

I love the activities that Colorado has to offer. I rock climb, backpack, hike, and ski. I’d much rather be outside than in a gym.

What surprised you the most about the physical therapist profession?

The most surprising aspect of PT to me is the fact that I still run into people, physicians, surgeons who don’t utilize PT or are unsure of how we can help as a profession.

Are you currently pursuing any further education/Certifications?

I’ve spent my continuing education with pelvic floor focus for male and female patient’s along with becoming certified in the Selective Functional Movement Assessment and Functional Movement Screen. I am a certified clinical instructor. I am currently searching for a gait/running analysis course.

What’s your go-to breakfast?

Bagels, breakfast tacos, oat meal…I love breakfast!

What do you wish everyone knew about physical therapy? / What is the biggest misconception you hear from new patients?

I just wish the general pubic as a whole knew more about how PT can help so that people didn’t suffer with pain for so long prior to seeking treatment.

What is the most important personality trait that a therapist must have?

Simply just caring about the profession. This is what drives us to continue with our education and put in the effort to spend time researching to find more effective treatment plans.

What do you do to de-stress/unwind?

Working out and reading both help me to de-stress in the evenings.

Finish this sentence: On Saturday mornings, you can usually find me…in the mountains!

What is your favorite piece of wellness advice to offer?

I think the medical profession as a whole needs to give more focus on nutrition and how poor/good nutrition has affects on our system globally.

Get to Know Your PT: Aaron Page, Therapydia Denver Physical Therapist

Therapydia Denver physical therapist Aaron Page takes some time to talk smoothies, his recent move to Colorado, and what he wishes everyone knew about PT.

“The best workout plan is something that’s sustainable. In order to create lasting change, it needs to be approachable and repeatable.”

When did you know that you wanted to be a physical therapist?

Like a lot of physical therapists I know, I was an athlete growing up and had my fair share of injuries, so I was exposed to PT early and often. I got to know a great PT in my area when I was 15 or so, and he was a clear example of someone who cared about his patients and I wanted to be a practitioner like that. I guess I officially knew in undergrad when I decided to switch my major from Biology to Health and Human Sciences and move forward to grad school with being a PT as my goal.

What is the biggest challenge involved in being a PT?

The biggest challenge for a PT (besides the paperwork) is not falling into specific patterns of treatment. It’s easy to start going down similar paths of rehab with patients that may be exhibiting similar characteristics. The important thing to keep reminding yourself that each patient is unique and small nuances in care can make a big difference, so you need to be constantly reflecting on your choices and adapting to new information.

How do you like to stay active?

I recently moved to Colorado so anything I can do outdoors like hiking or biking has been great. I’m a fan of resistance training too and try to incorporate that into my treatment sessions, so I’m training in the gym as well to make sure I don’t ask my patients to do anything I can’t do.

What’s your favorite song to get you motivated?

It’s kind of obscure, but my go-to song for motivation is “Quiet Little Voices” by We Were Promised Jetpacks. I like songs that build throughout and this one does that really well. It’s super helpful on a run when the tempo picks up and the band gets louder as you go on.

What surprised you the most about the physical therapist profession?

Realistically I think what most surprised me was the difficulty of navigating the healthcare system. It seems like it should be something that works for you when you need it, but often times we’re faced with the challenge of trying to provide quality care within the confines of an insurance plan that makes it difficult for patients and practitioners to access all of the benefits they pay for each month with their premium. It seems crazy to me to have to justify care in certain situations that warrant it and still have hoops to jump through to make it happen.

Are you currently pursuing any further education/certifications?

I’m in the process of reviewing to get my CSCS (Certified Strength and Conditioning Specialist) and plan on getting my OCS (Orthopedics Certified Specialist) in the next few years. In the mean time I’m looking to take a course on Functional Range Conditioning to update on some movement systems.

What is the biggest misconception you hear from new patients?

The biggest misconception I get all the time is that PTs just do massage and stretching. Though those can be helpful in their own way and are sometimes incorporated in a treatment plan, physical therapy is much more than that. I wish everyone knew that PTs are movement experts and evaluating how your body moves and can (or cannot) control movement is a unique and challenging aspect for clinicians. I always try to emphasize that the more active a patient is in their treatment the better the outcomes.

What’s your go-to breakfast?

I’m usually trying to get something quick, so I’m a big smoothie guy. My go-to is usually spinach, almond butter, bananas, some sort of berry and almond milk. It’s either that or some Greek yogurt, raspberries and granola. I basically eat the same thing every morning haha.

What is the most important personality trait that a PT must have?

Most importantly, physical therapists have to be compassionate. Truly listening to your patient and finding a way to meet them where they are is crucial. If you don’t value your patient’s goals as your own, it can be tougher to get them there.

What do you do to de-stress/unwind?

I usually try to read. I bounce back and forth between fiction and non-fiction, but it’s easy for me to get caught up in what I’m reading and it helps to take my mind out of its normal space.

Finish this sentence: On Saturday mornings, you can usually find me…

On my way to find an egg-everything bagel and an iced coffee treat.

What is your favorite piece of wellness advice to offer?

The best workout plan is something that’s sustainable. Sometimes we ask our patients to do a lot in the name of rehab, but what we’re trying to instill more often than not is consistency. In order to create lasting change, it needs to be approachable and repeatable.

Click here to learn more about Aaron and the other physical therapists at Therapydia Denver.

Get to Know Your PT: Josh Hardy, Therapydia Denver Physical Therapist

Therapydia Denver physical therapist Josh Hardy takes some time to talk about his love of the mountains, staying active year-round, and how a high school basketball injury led to a career in PT.

“Find fun things to do that will keep you fit. You’ll never work out another day in your life.”

When did you know that you wanted to be a physical therapist?

When I was a junior in high school. I fractured my pelvis during a basketball game and ended up doing a fair amount of PT to get ready for track season. Spending time with my physical therapist got me interested in anatomy and biomechanics and I never looked back.

What is the biggest challenge involved in being a PT?

Honestly, the paperwork. It is tough to give your patients what they need and deserve in each visit while staying on top of your charts. In a busy week, you can easily end up doing 10-15 hours of paperwork on top of seeing 40 hours worth of patients.

How do you like to stay active?

In the summertime I love to hike, cycle, camp, and fly fish. In the wintertime I love to snowboard and snowshoe.

What’s your favorite song to get you motivated?

“17 Years” by Ratatat. It can get me excited to do anything from snowboarding to paperwork. That song just really gets me going.

What surprised you the most about the physical therapist profession?

How much health insurance influences care. In situations where a lot of rehab is needed (ACL reconstruction, rotator cuff repair, etc.), you really have to look at the patient’s insurance situation and strategize about how to ensure that they make a full recovery within the confines of their benefits.

Are you currently pursuing any further education/certifications?

Next on my continuing education list is definitely a shoulder course. Bigger picture, I’m always considering going back to get my PhD and someday contribute to the PT profession as an educator.

What do you wish everyone knew about physical therapy?

With most insurance plans you can come straight to physical therapy. If you have a musculoskeletal issue, you can often save yourself a copay and potential added costs of imaging by going to the practitioner that is ultimately going to get you healthy again (your PT).

What’s your go-to breakfast?

2 farm freshies sunny side up, 1 strip of bacon, wheat toast.

What is the most important personality trait that a PT must have?

You have to be outgoing and enjoy speaking with people. A big part of the job is having 15 to 20, 30-minute conversations per day.

What do you do to de-stress/unwind?

I like to get out of the city and up into the hills. It doesn’t really matter what I’m doing, I’m always happy if I’m in the mountains.

Finish this sentence: On Saturday mornings, you can usually find me…

Heading west on I-70

What is your favorite piece of wellness advice to offer?

Find fun things to do that will keep you fit. You’ll never “work out” another day in your life.

Click here to learn more about Josh and the other physical therapists at Therapydia Denver.

5 Benefits of Pilates for New Moms

The amount of change that comes along with new motherhood is massive. Caring for a newborn, adjusting to a new life, new priorities—it’s not uncommon for new mothers to overlook their own personal well-being. Unfortunately, back pain, feelings of weakness, and muscle soreness are very common among mothers after giving birth.

There is a great deal of research showing the benefits of Pilates for feeling great, both physically and mentally. As an effective treatment technique used in physical therapy, Pilates encourages movement and doesn’t put too much stress directly upon the injured area while still providing the tools to increase strength and flexibility. There are a number of advantages of Pilates movements for new mothers in particular.


Remember not to return to exercise too soon after pregnancy and always follow the advice of your doctor or physical therapist. Pushing yourself too soon can potentially make recovery take even longer than if you waited the appropriate amount of time. Listen to your body and take breaks when necessary.