Clinical bottom line
Effective management of post-stroke spasticity and associated pain in palliative care requires individualized, goal-directed approaches combining pharmacologic and physical therapies. Recent evidence highlights the importance of structured goal setting and tailored physical treatment modalities to improve function and comfort in this population. Multimodal pain management strategies addressing both nociceptive and neuropathic components are essential. Despite advances, challenges remain in optimizing care due to variability in patient needs and limited palliative-specific protocols (Ashford et al., 2025; Lewis et al., 2024).
What the evidence shows
Ashford et al. (2025) conducted a meta-analysis examining goal setting and physical treatment categorization for focal spasticity following stroke or acquired brain injury. Their findings support that individualized goal-oriented rehabilitation combined with appropriate physical therapies—such as stretching, positioning, and neuromuscular electrical stimulation—can reduce spasticity severity and improve patient-centered outcomes.
Lewis et al. (2024) provide a practical primer for palliative care professionals emphasizing comprehensive spasticity evaluation, including assessment of pain, functional impairment, and quality of life. They advocate for integrating pharmacologic agents (e.g., oral antispasmodics, botulinum toxin injections) with physical modalities to optimize symptom control.
Pain in post-stroke spasticity is multifactorial, involving muscle overactivity, joint contractures, and central sensitization. Multimodal analgesia tailored to individual pain mechanisms is recommended, with careful consideration of side effect profiles in the palliative setting.
Breitbart et al. (2014) underscore the broader context of symptom management in palliative care, highlighting the need for holistic approaches addressing fatigue and psychosocial factors that may exacerbate pain and spasticity.
Caveats and uncertainty
Most studies focus on rehabilitation populations rather than exclusively palliative cohorts, limiting direct applicability.
Heterogeneity in spasticity severity, stroke etiology, and comorbidities complicates standardization of treatment protocols.
Evidence for long-term outcomes and optimal timing of interventions in palliative care remains sparse.
Balancing efficacy and tolerability of pharmacologic agents is challenging in frail patients.
Further research is needed to develop validated assessment tools specific to palliative care settings.
How this may change practice
Palliative care teams should incorporate structured goal setting and individualized physical therapy plans into spasticity management.
Early involvement of multidisciplinary specialists, including physiatrists and pain specialists, can enhance care coordination.
Use of botulinum toxin and other targeted pharmacotherapies may be expanded with appropriate monitoring.
Comprehensive pain assessment distinguishing spasticity-related pain from other etiologies will guide tailored analgesic regimens.
Education and training in spasticity management should be integrated into palliative care curricula to improve clinician confidence and patient outcomes.