Impact of Spasticity on ADLs and Motor Learning: A Guide for Occupational Therapists

Occupational therapist Elisabeth Coba Jiménez explores how spasticity influences activity performance and motor learning.

What is spasticity in the neurological patient?

There are many ways to define the concept of spasticity. Depending on the context—clinical, academic, or even everyday—the term takes on different nuances that do not always coincide. Rather than a closed definition, spasticity seems to be an idea that is better understood when observed in clinical practice.

Sometimes spasticity is described as “stiffness,” and at other times as “involuntary movements”; each description captures only part of the concept. 

Accordingly, it could be defined as the neurological phenomenon characterized by a velocity-dependent increase in muscle tone, accompanied by hyperreflexia, as a result of a central nervous system lesion, specifically involving the upper motor neuron. 

This phenomenon is observed in various neurological diseases, including stroke, cerebral palsy, multiple sclerosis, spinal cord injuries, traumatic brain injuries, and other conditions affecting the descending motor pathways.

How spasticity affects motor learning: challenges in therapy

Motor learning is an internal process associated with practice and experience that produces relatively permanent changes in the ability to perform movements. From an occupational therapy perspective, this process is essential for developing and optimizing occupational performance, as it enables the acquisition and adaptation of motor skills necessary for effective participation in activities of daily living. 

Occupational therapists’ intervention in this area focuses on the use of meaningful activities, task-oriented practice, and environmental adaptation to promote the individual’s function, independence, and participation.

At the physiological level, a number of mechanisms in the central and peripheral nervous systems are altered, which is why spasticity affects motor learning:

• Limitation of active and selective movement:
  • It makes movement dissociation difficult.
  • It promotes abnormal synergies.
  • It reduces the degrees of freedom of movement → fewer options for learning.

Impact: the nervous system learns compensatory patterns, not efficient movements. Here, the central nervous system reorganizes motor maps, and this is where the concept of brain plasticity emerges.

• Altered sensory feedback:
  • Increased tone modifies proprioception.
  • The brain receives distorted sensory information.

Impact: the ability to detect errors is reduced, which is key to motor learning.

• Fatigue and excessive effort:
  • Greater co-contraction.
  • Increased energy expenditure.

Impact: lower tolerance for intensive practice, which is essential for learning.

• Interference with variable practice:
  • Stiffness limits exploration of different motor strategies.

Impact: less transfer to real-world contexts (home, school, work).

How spasticity affects activities of daily living (ADLs)

From a neurofunctional perspective, muscle contraction represents only one element of motor organization, with movement resulting from the integration of higher cognitive processes —perception, attention, memory, and learning—that enable its planning, execution, and control.

Functional movement does not depend on a single brain area, but rather on the interaction of multiple structures that integrate cognitive, sensory, and motor information to enable purposeful actions. This integration is fundamental to participation in activities of daily living.

The structures involved are: 

1. Prefrontal cortex (intention, attention, and planning), 
2. premotor and supplementary motor areas (transform intention into a motor plan), 
3. primary motor cortex (movement execution), 
4. basal ganglia (movement selection and control), 
5. cerebellum (coordination, learning, and error correction) 
6. and the sensory systems (adjusting posture, regulating force, and guiding movement toward a goal). 

Overall, the proper integration and functioning of these structures is essential to ensure efficient motor control and proper postural organization. When this balance is disrupted, dysfunction in tone and postural control may arise, leading to abnormal motor patterns.

The postural alterations resulting from hyperactivity of muscle groups in both the upper and lower limbs often significantly interfere with performing activities of daily living (ADLs). The patient’s ability to perform functional movements required for basic activities such as dressing, undressing, personal hygiene, and eating is limited, as is the ability to perform instrumental and advanced activities, including home maintenance, driving, and other tasks requiring greater motor control and coordination.

Spasticity assessment Scales in occupational therapy

Accurately measuring spasticity makes it possible to address the underlying cause and plan more specific and effective interventions.

Among the Scales most commonly used by therapists to assess spasticity are: 

• Modified Ashworth Scale: measures muscle resistance to passive movement. It is a subjective scale that rates the degree of spasticity from 0 to 4.
• Tardieu Scale: assesses the muscle response to different degrees of passive stretching by measuring resistance to movement at different velocities. It is a more comprehensive scale because it includes the velocity item, which is very important for assessing spasticity.

Furthermore, comprehensive assessment of spasticity is fundamental in occupational therapy because it helps understand how this disorder of muscle tone affects the person beyond the muscle, affecting occupational performance, independence, and quality of life.

A comprehensive assessment guides clinical decisions such as:

• Use of splints or orthoses, with the aim of preventing deformities. 
• Environmental or task adaptations: occupational therapists are responsible for analyzing and adapting the environment, tasks, and so on to facilitate their completion.
• Tone inhibition or facilitation techniques, such as proprioceptive neuromuscular facilitation (PNF). 
• Training/retraining in meaningful activities: repeated practice of functional activities relevant to the patient is proposed, also integrating tone-control strategies.
• Education for family members and caregivers, which is essential for understanding what the patient is experiencing.

Clinical management of spasticity beyond botulinum toxin

Botulinum toxin is a neurotoxin administered to reduce muscle tone and spasticity in various neurological conditions (for example, after a stroke or in cerebral palsy). It acts by blocking acetylcholine release at the neuromuscular junction, which decreases motor neuron activity and reduces muscle resistance. Its effects usually last between 3 and 6 months.

Nevertheless, although it improves muscle tone, it does not by itself guarantee sustained functional improvements—such as walking better, grasping objects, or performing activities of daily living effectively. This is due to the following factors:

• Spasticity is only one of multiple factors that limit function (muscle weakness, loss of selective motor control, sensory impairments, and cognitive deficits also play a role).
• The toxin does not automatically restore movement patterns or coordination.
• Without specific training, the nervous system does not stably incorporate the changes in tone.
• The effects are temporary, so rehabilitation is required to consolidate functional gains.

Therefore, the greatest efficacy is achieved when botulinum toxin administration is integrated into a multidisciplinary rehabilitation program that includes physical therapy, occupational therapy, and goal-oriented functional training.

14 rehabilitation exercises after a stroke

From an evidence-based perspective, the use of botulinum toxin is supported by the scientific literature, particularly for treating spasticity secondary to stroke and cerebral palsy:

• Kaya Cs. et al. (2022), in their article on botulinum toxin for managing spasticity in cerebral palsy, address numerous clinical features that improve following its injection. These include a decrease in stiffness, reduced resistance to passive stretching, and improved passive muscle strength. Botulinum toxin administration has even been shown to produce changes in muscle structure that persist beyond the disappearance of the pharmacological effect.

• In the randomized clinical trial by Çelebi, G. et al. (2025), the results demonstrated that ultrasound-guided BT-A injection is an effective method for relieving pain caused by passive shoulder movement after stroke, significantly reducing spasticity and notably improving motor function.

• Furthermore, the study by Delgado et al. (2021) reinforces the importance of integrating physical and occupational therapy with botulinum toxin administration to maximize functional benefits in children with cerebral palsy.

Clinical strategies for managing spasticity in occupational therapy

Mobilization and stretching are very important in the treatment of spasticity in both occupational and physical therapy. In the upper limb, for example, these techniques make it possible to keep the hand open during everyday activities such as watching television or reading a book. 

In my work with neurological patients, I have seen that small adjustments to arm posture during the day can produce changes in spasticity, demonstrating how simple movement and positioning habits influence muscle function and body control.

In addition to posture and daily habits, spasticity treatment may benefit from tools such as transcutaneous electrical nerve stimulation (TENS). Recent studies show that TENS, used alone or with other therapies, can significantly reduce muscle stiffness in people who have had a stroke, with particularly notable improvements in the legs.

According to Marcolino et al. (2020), measurable reductions have been reported on clinical spasticity Scales such as the Modified Ashworth Scale. This confirms the technique’s efficacy as an adjunct in rehabilitation to improve functional movement.

The combination of dual-task exercises (cognitive + physical)—activities that require patients to think while moving—promotes coordination, attention, and memory. Activities that require thinking and promote attention and memory would be cognitive aspects.

An example of a session with dual-task exercises could involve: 

• Learning and repeating a sequence of hand movements: squeezing a ball, rotating the wrist, opening and closing the fingers, while naming words or numbers from a previously provided list. 

In occupational therapy for patients with spasticity, the use of resting splints for the upper limb is recommended to prevent deformities, as are AFO (Ankle-Foot- Orthoses) orthoses for the lower limbs when indicated, with ongoing monitoring of skin tolerance and progressive adjustments according to the patient’s progress, with the aim of maintaining joint range of motion, preventing deformities, and supporting function. Likewise, it is recommended to incorporate built-up or adapted utensils to facilitate grasp and promote independence in activities of daily living (ADLs), together with training in compensatory techniques to optimize functional performance.

It is essential to prioritize proximal control and trunk stability before working on fine-motor tasks, as proximal stability supports distal precision. In addition, proper postural alignment should be maintained in sitting and lying, using cushions or wedges as needed, and repositioning should be performed every two hours in patients with reduced mobility to prevent secondary complications such as pressure ulcers and joint stiffness.

Conclusion

Spasticity is a complex challenge that affects mobility, function, and quality of life in people with neurological injuries. Both small postural adjustments in daily life and specific therapeutic interventions can modulate muscle stiffness and improve function. 

However, its most effective management emerges when it is addressed through an interdisciplinary approach, integrating the work of physical therapists, occupational therapists, neuropsychologists, and other health professionals. This collaboration makes it possible to combine physical, cognitive, and functional strategies tailored to each patient, maximizing recovery, promoting independence, and supporting a holistic approach to neurological care.

References

• Çelebi, G., Ayyildiz, A., Çiftci Inceoğlu, S., & Kuran, B. (2025). The effect of ultrasound-guided botulinum toxin injections on pain, functionality, spasticity, and range of motion in patients with post-stroke upper extremity spasticity. Rehabilitación (Madr), 59(1), 100876. https://doi.org/10.1016/j.rh.2024.100876
• Delgado, M. R., Tilton, A., Carranza-Del Río, J., Dursun, N., Bonikowski, M., Aydin, R., Maciag-Tymecka, I., Oleszek, J., Dabrowski, E., Grandoulier, A. S., & Dysport in PUL Study Group. (2021). Efficacy and safety of abobotulinumtoxinA for upper limb spasticity in children with cerebral palsy: A randomized repeat-treatment study. Developmental Medicine & Child Neurology, 63(5), 592–600. https://doi.org/10.1111/dmcn.14733
• Gal, O., Baude, M., Deltombe, T., Esquenazi, A., Gracies, J.-M., Hoskovcova, M., Rodriguez-Blazquez, C., Rosales, R., Satkunam, L., Wissel, J., Mestre, T., Sánchez-Ferro, Á., Skorvanek, M., Tosin, M. H. d. S., Jech, R., & MDS Clinical Outcome Assessments Scientific Evaluation Committee and MDS Spasticity Study Group. (2025). Clinical outcome assessments for spasticity: Review, critique, and recommendations. Movement Disorders, 40, 22–43. https://doi.org/10.1002/mds.30062
• Kaya Keles, C., & Ates, F. (2022). Botulinum toxin intervention in cerebral palsy-induced spasticity management: Projected and contradictory effects on skeletal muscles. Toxins, 14(11), 772. https://doi.org/10.3390/toxins14110772
• Marcolino, M. A. Z., Hauck, M., Stein, C., Schardong, J., Pagnussat, A. S., & Plentz, R. D. M. (2020). Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: Systematic review and meta-analysis of randomized controlled trials. Disability and Rehabilitation, 42(5), 623–635. https://doi.org/10.1080/09638288.2018.1503736
• Roldán-González, E., Gómez-Rodríguez, F. J., Jácome-Velasco, S. J., Riascos-Forero, Y., Rosas-Roldán, L. A., Hurtado-Otero, M. L., & Sarria-Gómez, A. V. (2024). Validez y fiabilidad de la escala de Tardieu para evaluar la espasticidad en miembro superior en adultos con enfermedad cerebrovascular: Revisión sistemática [Validity and reliability of the Tardieu scale for assessing upper limb spasticity in adults with cerebrovascular disease: Systematic review]. Revista de Neurología, 79(2), 41–49. https://doi.org/10.33588/rn.7902.2024093

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