Paralysis and Spasticity — Where the Command Breaks Shapes What Follows

The Same "No Strength," Two Different Arms

Let us imagine two people. One has collapsed from a blocked cerebral blood vessel and cannot properly use their right arm and leg. For the first few days, the right arm hung limply, but after a few weeks, the elbow remains bent, and the arm resists when family members try to straighten it. The other person lost strength in their hand after injuring a nerve in the arm. This hand does not resist and dangles limply, and the muscles of the hand visibly wasted away over the course of several months.

Both people say, "I have no strength." Yet the shapes the arms show are almost opposite. One arm resists, and the other sags. This difference comes from where in the body the instruction to "move" was cut off.

This article follows the path down which that instruction travels. We look in turn at how the body breaks down differently depending on where the pathway is cut, what hospitals do at that time, how walking and falls are handled, and whether injured nerves grow back.

The Orders Go Down in Three Steps

What this article looks at, among the many things rehabilitation deals with, is moving the body. Rehabilitation is treatment and care that help people whose everyday functioning has decreased—or is at risk of decreasing—due to illness, injury, or aging, to recover and maintain their functions so they can live their lives again. Function is what the body and mind accomplish, encompassing everything from body movements to daily activities like getting dressed and walking, to roles within the workplace and the family. The full picture of rehabilitation is drawn by another part of this series, 「Rehabilitation」.

When you decide to pick up a cup, that order starts in the brain and first travels down to the spinal cord. The spinal cord is a central nervous system pathway that extends from the brain down along the inside of the backbones, serving as a route where commands and sensations travel between the brain and the body while housing nerve cells. Here, the central nervous system is the collective name for the brain and the spinal cord, distinguishing them from the nerves branching outside them. When the order starting anew from the spinal cord reaches the muscles of the arms and legs, the muscles contract. Compared to a company, the brain is the headquarters, the spinal cord is the branch office, and the muscles are the field.

The nerve cells that carry orders from headquarters to the branch office, and from the branch office to the field, are different from one another. Upper motor neurons are nerve cells that send movement orders down from the brain to the spinal cord. Orders for voluntary movements mainly ride down nerve bundles that run straight from the motor region of the brain to the spinal cord. Lower motor neurons are nerve cells that deliver orders directly from the spinal cord to the muscles.

Nerve cells extend long branches from their cell bodies and send signals all the way to the ends of those branches. The cell body of a lower motor neuron is inside the spinal cord, and only its long branch exits the spinal cord, passes through a peripheral nerve, and reaches the muscle. Peripheral nerves are nerves that branch out from outside the brain and spinal cord, connecting to the arms, legs, and various parts of the body. Peripheral nerves contain both strands that send orders downward and strands that send sensations upward. Therefore, injuring a peripheral nerve can cause you to lose sensation along with strength (PMID 10219748). Orders go out to the muscles of the face, tongue, and throat from the lower end of the brain in the same way. This article follows those along the limbs.

The branch office does not merely relay orders; it runs reflexes on its own. A reflex is a reaction that occurs automatically to a stimulus, regardless of your will. When a muscle is suddenly stretched, the spinal cord makes that muscle contract right back without going through the brain. The leg jumping up when the area below the knee is tapped with a rubber mallet is this reflex. Headquarters ordinarily sends down both signals that suppress this reflex and signals that encourage it, adjusting the reflex to an appropriate intensity (PMID 11918643).

At the end of this path, the muscle exerts force. Muscle strength is the force that can be generated by contracting a muscle of one's own will. All the stories that follow rely on two things. Movement is a single line of orders running from headquarters to the branch office to the field. And the branch office runs its own reflexes right in the middle of it.

The Pattern Varies Depending on Where the Break Is

First, consider the case where the line from headquarters to the branch office—that is, the upper motor neuron—is cut. In this scenario, the branch office is intact, and the line from the branch office to the worksite is also fine. What has been lost is the intent and regulation of headquarters. As a result, the force that can be exerted by will is weakened, and the reflexes of the spinal cord, which have lost their regulation, become exaggerated (PMID 11918643). Tapping a tendon produces a brisk reflex, bending the ankle triggers a sustained tremor, and the limbs may spontaneously flex or extend. All of these symptoms are viewed as a single bundle because they represent the muscle working excessively (PMID 11918643).

One common disease that injures upper motor neurons is a stroke. A stroke is a condition in which the blood supply to the brain is suddenly blocked or bursts, damaging the brain tissue that was receiving that blood. A stroke in one side of the brain commonly leaves hemiplegia on the opposite side of the body. Hemiplegia is a state in which the limbs on one side of the body lose strength or cannot move at all.

Injuring the spinal cord produces the same type of changes in the body below the site of the injury (PMID 32304496). The spinal cord is a narrow pathway through which instructions destined for both sides of the body travel together. Therefore, spinal cord injuries commonly affect both sides of the body. An injury at the neck level affects all four limbs, while an injury further down primarily affects both legs. Right at the exact level of the injury, the lower motor neurons at that segment may be damaged as well. When this happens, the muscles governed by that level may exhibit a different pattern, which we will look at later.

Changes where reflexes become exaggerated often appear some time after the injury rather than immediately (PMID 19769916). The arm of the first person, which hung limply for the first few days and then began to resist after several weeks, is an example of this. Such muscle-resisting changes occur in many people who have experienced a stroke, but not in all of them (PMID 26522902). Conversely, it is also common for reflexes to subside again over time.

The fact that these changes arrive late and change again means they cannot be explained solely by the loss of headquarters' regulation. It suggests that the central nervous system itself, including the spinal cord, changes over time (PMID 11918643). The headquarters-and-branch analogy cannot capture that. The pattern that remains after injuring the brain or spinal cord is determined less by the cause of the injury than by which site was injured, how widely, and how much time has passed since the injury (PMID 11918643).

Now consider the case where the line from the branch office to the worksite—that is, the lower motor neuron—is cut. The muscle receives neither the instructions of intent nor the instructions of reflexes. Strength drops, reflexes diminish, and the muscle wastes away (PMID 39740575). Muscle atrophy is the thinning and shrinking of muscle. Because the final link of the reflex is broken, the muscle does not resist and instead hangs limply. The hand of the second person, who injured an arm nerve, is an example of this.

This pattern in the arm does not only appear when peripheral nerves are injured. It can also occur in conditions where blood supply to the spinal cord is blocked or the spinal cord is compressed in the cervical (neck) region (PMID 39740575). When the pathology is inside the spinal cord like this, the body below the injured level may simultaneously display the pattern of upper motor neuron injury we saw earlier.

The reason doctors test reflexes with a rubber mallet lies in this table. Whether reflexes are exaggerated or diminished serves as a clue indicating where the signal was cut. However, immediately after a brain or spinal cord injury, reflexes may actually be weak. Therefore, location cannot be diagnosed based on a single reflex alone.

The final row of the table refers only to cases where muscles waste away because a nerve is cut. Even if a nerve is not cut, it is common for muscles to shrink and the body to become frail following a stroke. This state is associated with less functional recovery and reduced rehabilitation outcomes (PMID 41373228).

Strength, Tone, and Spasticity Are Different Things

A family member trying to straighten a bent elbow will hear three terms in the hospital room: strength is low, tone is high, and spasticity is present. Strength, or muscle strength, was covered earlier. The other two become apparent when someone else moves the arm or leg. Muscle tone is the resistance of the muscle felt when someone else moves the limbs while the person is relaxed. Saying tone is high means this resistance is large (PMID 19769916).

Spasticity is a state where the reflex of contracting back when a muscle is stretched becomes excessively large, so that the faster the muscle is stretched, the stronger the resistance becomes. This definition is often called "Lance's definition" after the scholar who organized it, and its core is speed (PMID 19632962). If you slowly straighten a bent elbow, it resists less; if you straighten it quickly, it resists more. Limbs also become stiff in Parkinson's disease, but that stiffness does not change with speed in this way. In this respect, it is distinguished from spasticity (PMID 11918643, PMID 6926389).

High muscle tone does not mean everything is spasticity. Three things are mixed into the resistance the arm puts up after an injury to the brain or spinal cord. One is spasticity created by reflexes during a stretch. Another is the muscle continuing to contract even when not stretched. The last is that the muscle and surrounding tissues themselves have become stiff (PMID 19769916). The Ashworth scale, commonly used in hospitals, assesses the magnitude of this resistance by hand and scores it. However, it does not reliably separate spasticity from tissue stiffness within that resistance (PMID 19769916).

Tissue stiffness grows on its own. If a muscle remains shortened for a long time, the tissue becomes stiff. This is true whether movement is impossible due to weakness or because the muscle is contracted. That stiffness increases resistance, holding the muscle back in its shortened state. If this loop continues, it eventually settles into a permanently shortened state (PMID 19769916).

A contracture is a state where the muscles and tissues around a joint have shortened and stiffened, reducing the range of motion of the joint and making it rigid. Contracture is a common complication after stroke. It interferes with using the limbs and also creates hygiene issues such as washing (PMID 39312271).

Just because an arm resists strongly due to spasticity does not mean the arm has become strong. Spasticity usually arrives together with weakness (PMID 26522902). And what makes movement difficult is usually weakness rather than excessive contraction (PMID 11723387). The contraction of spasticity is created by branch reflexes, regardless of the headquarters' intentions. Therefore, it cannot become usable force for picking up a cup.

Spasticity Is Addressed According to Set Goals

There are multiple ways to address spasticity. Non-drug methods like exercise therapy (PMID 25408747) and drug treatments are commonly used together, and which ones to use are chosen according to pre-determined goals (PMID 26522902). Most commonly used drugs have evidence for efficacy and safety. However, more evidence is needed on how much those treatments actually change the ability to use arms and legs, and what happens when multiple methods are combined (PMID 26522902). This means that while evidence that drugs manage spasticity has accumulated, evidence on whether that helps people use their arms and legs better is still lacking.

Botulinum toxin injections placed directly into muscles show this gap well. These injections make the injected muscle contract less for a while. The effect of the injection in reducing spasticity is clear. However, a review published in 2001 summarized that the double-blind, placebo-controlled trials up to that point had difficulty showing that self-directed functional abilities improved (PMID 11723387). A double-blind, placebo-controlled trial is a test that compares a real drug to a fake drug while keeping both the patient and the evaluators unaware of who received the real drug.

The authors traced much of the reason to trial design. They reported that choosing which patients, how to give the injections, and what to use to measure outcomes were problematic, and wrote that the trials needed to be redesigned. Meanwhile, they added that clinical experience shows cases where carefully selected patients experience reduced spasticity along with improvements in self-directed movement and function (PMID 11723387). Trials published after that are not included in the reference list of this article. The reduction of spasticity and the ability to use an arm better are not the same thing.

Therefore, goals differ from person to person. Treatment is not given simply because spasticity is present. For some people, leg spasticity serves as support. It props up the leg when standing with weight-bearing or transferring from a bed to a chair. If spasticity is significantly reduced in such a person, standing may actually become harder.

Arms with severe spasticity and contractures are sometimes reconfigured through surgery. The goals selected at this time include reducing pain, hygiene such as washing, restoring function, and correcting stiff joints. Severely stiff joints may have limitations in being corrected with injections or braces alone, so surgery is used (PMID 32304496). Therapists first evaluate how abnormal muscle tone actually affects that person's movement and function (PMID 30626513). The Canadian Stroke Best Practice Recommendations also list spasticity as an item for rehabilitation to address (PMID 41257457).

There is a concern that strengthening exercises increase spasticity. A meta-analysis is an analysis that gathers the results of multiple trials and calculates them together. In a meta-analysis gathering strength training trials after stroke, strength training increased strength and daily activities in small but clear ways, and results showing that it increased spasticity did not appear (PMID 17132118). The authors concluded that strength training should become part of stroke rehabilitation.

However, it has not been clearly confirmed whether walking also improves together when strength increases. The chronic phase is the period several months after onset. In an analysis gathering lower limb strength training for chronic stroke patients, strength and the "Timed Up and Go" test improved. However, the difference in walking and balance scores was not distinct (PMID 26969343).

Splints, braces, and electrical stimulation used to prevent or relieve contractures still have weak evidence. What has been gathered is only seven small randomized trials. A randomized trial is a test that compares interventions by randomly dividing people to receive them like a draw. Certainty is the degree to which one can trust that the conclusion will not change even if more research comes out in the future. All seven trials had very low certainty, making it impossible to conclude their effectiveness compared to usual care (PMID 39312271).

There were also trials where pain or skin damage was reported. However, it was also difficult to clearly ascertain whether there was harm, and the authors wrote that more studies providing sufficient stretching intensity and duration are needed (PMID 39312271). Saying the evidence is weak means there are still few studies that properly measured the effect. It is not a verdict that it works or does not work.

Walking Is Something Multiple Abilities Pull Off All at Once

Let us imagine a person walking down a hospital hallway. Gait is the medical term for the act of walking. In rehabilitation, whether someone can walk independently, how fast they walk, and how far they walk are measured separately (PMID 40365867).

Three changes are observed in the stride of someone whose leg has grown weak after a stroke. Their speed slows down, left and right become misaligned, and the energy it takes to walk increases (PMID 26969343).

The ways balance can break down are even more diverse. The sensations rising from the sole of the foot and the joints, the way the body works to keep from falling, the physical constraints of bones and joints, the mental work of dividing attention, and the sense of which way is standing straight all have a stake in balance. If any one of these goes out of alignment, balance shakes (PMID 19235121). A gait left behind by hemiplegia narrows the range in which a person can travel and raises the risk of falling (PMID 15736000). All of these things are tied up in a single step at the same time.

That is why the things rehabilitation does for walking are also multiple. Physical rehabilitation that mixes several elements is likely helpful in regaining everyday activities and mobility after a stroke. The method of practicing actual tasks to be done can also be useful (PMID 39932103). This conclusion gathers 267 studies and 21,838 participants. However, because the studies differ from one another, the certainty is limited (PMID 39932103). Approaches leaning on neurophysiological theory—in other words, theory about how nerves work—may not be better than other approaches or could be less effective (PMID 39932103).

The help of machinery is also used. There is training that makes people walk while assisting leg movement with a robot or motorized device. Adding this training to physical therapy appears likely to raise the chance of becoming able to walk independently, and the certainty of this evidence is moderate (PMID 40365867). The authors calculated that if nine people are treated this way, one of them escapes the state of relying on someone else's help for walking. However, walking speed hardly increased. In data tracked after the training ended, it was uncertain whether the difference in the proportion of independent walkers was maintained (PMID 40365867).

The authors wrote that these results must be read with caution. This is because some trials gathered people who could already walk from the start, and the devices used, training periods, and frequencies also varied from trial to trial (PMID 40365867).

Treadmill training, whether using a body-weight support device or not, did not raise the chance of walking independently compared to other walking physical therapies. The certainty of this evidence is low (PMID 28815562). Walking speed and endurance could improve slightly in the short term, and those gains appeared mainly in people who could walk from the start (PMID 28815562). Evidence that those improvements last a long time was not found (PMID 28815562).

The two results cannot be directly weighed against each other. The robot results looked at when it was added to physical therapy, while the treadmill looked at when it was done instead of other walking therapies, so it is not the result of a direct comparison between the two. There is also an analysis showing that in chronic stroke, group training that rotates through practicing various walking tasks increased walking distance and speed. However, this gathers only six small trials (307 people) (PMID 19461035).

Either method targets one part of walking. Why what is practiced and how much of it matters, and how long improvement can continue, are stories of the principles by which the brain learns anew. That story is handed over to another part of this series, "Neuroplasticity".

Falls Are About Knowing the Risks and Preparing

For the family of someone who has started walking down the hallway, the worry about what will happen if they fall follows them. A fall is an unintentional incident of falling or dropping to the floor or a lower level. Falls after a stroke are common. They occur when symptoms left by brain injury overlap with muscle loss and weakness (PMID 41373228).

The article summarizing this is a narrative review. A narrative review is an article where authors select and read studies and summarize them in words, without pooling and calculating the results together. This review concludes that a multifactorial intervention combining exercise, nutrition management, psychological support, and systematic fall prevention can reduce weakness, muscle loss, and falls. It also suggests using fall risk assessment tools at scheduled times (PMID 41373228). The Canadian stroke best practice recommendations also include fall risk as an item that rehabilitation should address (PMID 41257457).

Trunk control training improved sitting and standing balance and mobility after stroke (PMID 30791703). Better balance does not directly mean fewer falls. However, balance is one branch that makes up fall risk.

The fear of falling is also something to address. This fear is associated with serious physical and psychological consequences (PMID 25432016). In older adults living in the community, exercise slightly reduced fear immediately after it ended, and did not increase the risk or frequency of falling. This group was not limited to stroke, and the certainty of the evidence is low (PMID 25432016). In an analysis pooling neurological conditions, when looking only at patients with stroke and spinal cord injury, the difference that physical therapy reduced fear was not clear (PMID 32745544). Falls are addressed by assessing risks and fixing multiple factors together.

Nerves That Grow Back, and a Brain That Finds Another Way

Let us return to the arm of the second person. The branches inside a peripheral nerve can be cleanly severed by a knife, or crushed so severely that the outer wrapping remains while the inner branches snap. In either case, the branches below the injury site collapse and are cleared away. This very process of collapse and clearance creates the room for new branches to grow (PMID 10219748).

Cells wrapped around the nerve line up to form a tube, guiding the outward-growing branches from above along that tube (PMID 10219748). After an injury, these cells switch to a state suited for repair (PMID 34595734). A branch that used to go to a muscle has a strong tendency to head back toward that muscle (PMID 10219748). However, it does not always find its original muscle.

Cases of mild compression, such as the paralysis that happens after sleeping on an arm, are different. Usually, the branches are not severed, just blocked from sending signals, so the problem often resolves without needing to grow anew.

The speed at which severed branches grow back is slow. Although there are regeneration speeds measured in basic research, those values are not used to calculate how long it takes for a person to get better. Whether they grow back and how much function returns also vary depending on the severity and location of the injury. A completely cut nerve is difficult to reconnect on its own, so it is usually joined surgically. With the use of microscopic surgery performed under a microscope, the quality of repair has improved significantly (PMID 12443569).

Recovery is the return of movement or function in the same way as before the injury. For peripheral nerves, recovery means new branches reaching the muscle and transmitting instructions just like before.

Nerves within the brain and spinal cord do not grow long distances again the way peripheral nerves do. The process by which the first person's arm moves again happens in a different way, and that story is picked up by another part in this series, Neuroplasticity.

The "weakness" of the two people takes these different paths. Where the instructions are cut off determines the pattern, and that pattern determines what can be done.

Where to Look Next

• To learn about spasticity and its surrounding symptoms in more detail, continue to "One Word, "Spasticity" — Reading the Upper Motor Neuron Syndrome Apart" from the "Rehabilitation Basics" series.
• The process by which peripheral nerves grow back and its conditions are covered by "How Peripheral Nerves Recover — An Introduction to Nerve Regeneration" in the same series.
• How injured brains and spinal cords change leads to "How the Central Nervous System Recovers — A Primer on Neuroplasticity".
• By what yardsticks outcomes like walking speed and walking independently are measured is found in "How Do We Measure Recovery — An Introduction to Rehabilitation Outcome Measures".
• Why walking practice is structured in that shape is covered by "Why Therapy Is Designed That Way — An Introduction to Motor Learning Principles".
• What a stroke is and which signs mean you must hurry are covered by "What a Stroke Actually Is — Blocked, Burst, and the Clock".
• Other installments in this series, "Rehabilitation", cover the rehabilitation team and goal setting, "Neuroplasticity" covers the timing and principles of improvement, and "Swallowing, Speech and Language" covers swallowing and speech.

Source Papers

• "Tonic stretch reflex threshold as a measure of spasticity: implications for clinical practice." (2009) — PMID 19632962 — Lance definition: tonic stretch reflex threshold, velocity-dependent phenomenon. Lack of consensus on measurement conceptual units.
• "The pathophysiology of spasticity." (2002) — PMID 11918643 — Spasticity is a positive phenomenon of upper motor neuron syndrome, hypertonia due to enhanced tonic stretch reflex, distinguished from rigidity by velocity dependence. Upper-level damage disinhibits spinal reflexes. Delayed onset and decreases over time. Syndrome depends on location, extent, and elapsed time rather than cause.
• "Spastic hypertonia and movement disorders: pathophysiology, clinical presentation, and quantification." (2009) — PMID 19769916 — Spasticity is a delayed consequence of upper pathway damage. Hypertonia = increased resistance to passive movement at rest, mixed with spasticity, spastic dystonia, and soft tissue stiffness. Tissue shortening → self-sustaining stiffness → contracture. Ashworth cannot distinguish between spasticity and tissue stiffness.
• "Disordered muscle tone and movement." (1981) — PMID 6926389 — Increased tone, rigidity, and decerebrate rigidity in Parkinson's disease have fundamentally different stretch reflex discharge patterns.
• "Spasticity Management After Stroke." (2015) — PMID 26522902 — Spasticity usually accompanies paralysis, combination of non-pharmacological and pharmacological treatments, according to pre-determined goals. Most drugs have efficacy and safety evidence, but functional outcome and combination evidence are needed more.
• "Botulinum treatment of spasticity: why is it so difficult to show a functional benefit?" (2001) — PMID 11723387 — Botulinum clearly reduces spasticity, but double-blind trials have difficulty proving active functional improvement. Movement disorders are usually due to negative symptoms such as weakness. Failures are largely due to methodology (patient selection, injection protocols, outcome measures) and require redesign.
• "Data condensed synthesis regarding kinesiotherapeutic procedures used in spasticity therapy." (2014) — PMID 25408747 — Summarizes major kinesiotherapy techniques used in spasticity treatment.
• "Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures." (2020) — PMID 32304496 — Spasticity is the result of upper motor neuron damage caused by brain and spinal cord injury. Reconstruction goals: quality of life, pain, hygiene, function, and joint contracture correction.
• "Muscle Overactivity in the Upper Motor Neuron Syndrome: Assessment and Problem Solving for Complex Cases: the Role of Physical and Occupational Therapy." (2018) — PMID 30626513 — Therapists evaluate the impact of abnormal muscle tone on function and active movement.
• "Cervical lower motor neuron syndromes: A diagnostic challenge." (2025) — PMID 39740575 — Lower motor neuron syndrome: muscle atrophy, weakness, and decreased reflexes.
• "Nerve injury, axonal degeneration and neural regeneration: basic insights." (1999) — PMID 10219748 — Wallerian degeneration, Schwann cell tubes guide regeneration, axonal damage causes weakness and sensory loss, motor fibers preferentially reinnervate muscle, regeneration speed crush 3~4 mm/day, transection 2~3 mm/day (basic research values — text states these are not numeric values to be used as a yardstick for human recovery periods).
• "Lessons from Injury: How Nerve Injury Studies Reveal Basic Biological Mechanisms and Therapeutic Opportunities for Peripheral Nerve Diseases." (2021) — PMID 34595734 — Formation of repair Schwann cell states following injury.
• "Progress of peripheral nerve repair." (2002) — PMID 12443569 — Significant improvement in the quality of nerve repair following the introduction of microsurgery.
• "Assistive technologies, including orthotic devices, for the management of contractures in adults after a stroke." (2024) — PMID 39312271 — Contracture = decreased joint range of motion and increased stiffness, common stroke complication, hinders function and hygiene. All 7 assistive technology RCTs have very low certainty, firm conclusions cannot be drawn, and pain and skin damage are reported.
• "Strengthening interventions increase strength and improve activity after stroke: a systematic review." (2006) — PMID 17132118 — Strengthening interventions make a small increase in strength (SMD 0.33) and activity (SMD 0.32) and do not increase spasticity. Concludes it should be part of rehabilitation.
• "Muscle strengthening for hemiparesis after stroke: A meta-analysis." (2016) — PMID 26969343 — Muscle weakness causes reduced walking speed, asymmetry, and energy cost. Lower limb strengthening in the chronic phase: significant for strength and TUG, non-significant for gait and BBS.
• "Canadian Stroke Best Practice Recommendations Rehabilitation, Recovery, and Community Participation Following Stroke, Part Two" (2026) — PMID 41257457 — Rehabilitation module topics include spasticity and fall risk.
• "Electromechanical-assisted training for walking after stroke." (2025) — PMID 40365867 — Latest Cochrane edition. Physical therapy combined with electromechanical-assisted gait training likely increases the likelihood of independent walking (moderate certainty), NNT 9. Walking speed barely increases, and it is uncertain whether independent walking is maintained at follow-up (low certainty).
• "Treadmill training and body weight support for walking after stroke." (2017) — PMID 28815562 — Latest Cochrane edition, 56 studies, 3,105 participants. No increase in the likelihood of independent walking (low quality), speed and endurance may improve slightly in the short term (moderate quality), benefits mainly seen in people able to walk from the start, and sustained effects of improvement were not found.
• "Effects of task-oriented circuit class training on walking competency after stroke: a systematic review." (2009) — PMID 19461035 — Task-oriented circuit class training improves walking distance and speed in chronic stroke.
• "Physical rehabilitation approaches for the recovery of function and mobility following stroke." (2025) — PMID 39932103 — 267 studies, 21,838 participants. Physical rehabilitation is likely to improve recovery of function and mobility, functional task training can be useful, and neurophysiological approaches show no difference or are less effective. Certainty limited by heterogeneity.
• "Balance control in hemiparetic stroke patients: main tools for evaluation." (2008) — PMID 19235121 — Balance problems arise from impairments in multiple systems, such as sensory input, movement strategies, biomechanical constraints, cognitive processing, and vertical perception.
• "Task-oriented aerobic exercise in chronic hemiparetic stroke: training protocols and treatment effects." (2005) — PMID 15736000 — Hemiparetic gait limits mobility and increases fall risk.
• "Narrative Review on Post-Stroke Outcomes Through Recognition of Frailty, Sarcopenia, and Palliative Care Needs." (2025) — PMID 41373228 — Narrative review. Frailty and sarcopenia are common after stroke and predict worse functional outcomes and rehabilitation response. Falls are a combination of neurological deficits and frailty and sarcopenia. Multicomponent interventions can reduce frailty, sarcopenia, and falls, and timing for screening tools is suggested.
• "The effectiveness of trunk training on trunk control, sitting and standing balance and mobility post-stroke: a systematic review and meta-analysis." (2019) — PMID 30791703 — Trunk training improves trunk control, sitting/standing balance, and mobility.
• "Exercise for reducing fear of falling in older people living in the community." (2014) — PMID 25432016 — Community-dwelling older adults (not limited to specific diseases). Fear of falling is associated with serious physical and psychosocial consequences. Exercise has a limited short-term reduction in fear and does not increase fall risk or frequency (low quality).
• "Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis." (2021) — PMID 32745544 — Effective in Parkinson's disease and multiple sclerosis, no significant between-group difference in stroke and spinal cord injury.