{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T08:47:00Z","timestamp":1785833220048,"version":"3.56.0"},"reference-count":35,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T00:00:00Z","timestamp":1785456000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Background: Stroke remains a leading cause of long-term disability worldwide. Post-stroke spasticity (PSS) is increasingly recognized as a complex complication resulting from the interaction between neural hyperexcitability and non-neural muscular adaptations, including fibrosis, altered muscle architecture, and increased stiffness. Consequently, effective management requires a comprehensive approach targeting both components. Musculoskeletal ultrasound (MSK US) has emerged as a practical tool for muscle characterization, treatment targeting, and longitudinal monitoring within neurorehabilitation programs. Aim: To propose a clinical practice framework integrating serial MSK US into multimodal PSS management and to illustrate its application through a proof-of-concept clinical case. Methods: The proposed framework combines standardized clinical assessment, serial MSK US evaluation, BoNT-A injections, physical modalities (neuromuscular electrical stimulation and extracorporeal shock wave therapy), and task-oriented rehabilitation. Ultrasound findings, including muscle echogenicity, architecture, and Modified Heckmatt Scale (MHS) characteristics, were integrated with clinical outcomes and rehabilitation goals to support individualized decision-making. Results: Serial MSK US provided complementary information regarding muscle quality and potential non-neural contributors to spasticity syndrome, supporting treatment planning and follow-up. Although only modest morphological changes were observed over time, the illustrative case showed favorable changes in clinical assessments including spasticity, motor performance, gait, and functional independence following the multimodal intervention. Conclusions: This proof-of-concept framework highlights the potential role of serial MSK US as a practical decision-support and monitoring tool within multimodal PSS management. Integrating clinical assessment with ultrasound-informed evaluation of both neural and non-neural components may facilitate more individualized rehabilitation strategies and optimize functional outcomes. Further studies are warranted to validate and standardize this approach.<\/jats:p>","DOI":"10.3390\/life16081271","type":"journal-article","created":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T13:23:20Z","timestamp":1785504200000},"page":"1271","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Clinical Practice Framework for Ultrasound-Informed Multimodal Management of Post-Stroke Spasticity: A Proof-of-Concept Case"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9016-8461","authenticated-orcid":false,"given":"Emanuela Elena","family":"Mihai","sequence":"first","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania"},{"name":"Department of Physical and Rehabilitation Medicine, Elias University Emergency Hospital, 011461 Bucharest, Romania"},{"name":"Spectra LV Institute, Vancouver, BC V5Z 2G9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matei","family":"Teodorescu","sequence":"additional","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Elias University Emergency Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eugenio","family":"Moita Gon\u00e7alves","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Hospital da Prelada, 4250-449  Porto, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajiv","family":"Reebye","sequence":"additional","affiliation":[{"name":"Spectra LV Institute, Vancouver, BC V5Z 2G9, Canada"},{"name":"Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 2G9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mihai","family":"Berteanu","sequence":"additional","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania"},{"name":"Department of Physical and Rehabilitation Medicine, Elias University Emergency Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1177\/17474930241308142","article-title":"World Stroke Organization: Global Stroke Fact Sheet 2025","volume":"20","author":"Feigin","year":"2025","journal-title":"Int. J. Stroke"},{"key":"ref_2","first-page":"3238165","article-title":"Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life","volume":"2018","author":"Donkor","year":"2018","journal-title":"Stroke Res. Treat."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"634","DOI":"10.2471\/BLT.16.181636","article-title":"Stroke: A global response is needed","volume":"94","author":"Johnson","year":"2016","journal-title":"Bull. World Health Organ."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Moita Gon\u00e7alves, E., Mihai, E.E., Costa, J., Andrade, I., Verraest, X., Pereira, P., P\u00edtrez, J., Filipe, B., Gonzales, L., and Berteanu, M. (2025). Multimodal treatment in spasticity management: An educational case-based international perspective. J. Int. Soc. Phys. Rehabil. Med., 10.1097.","DOI":"10.1097\/ph9.0000000000000075"},{"key":"ref_5","first-page":"e146","article-title":"Early recognition and intervention for poststroke spasticity: A scientific statement from the American Heart Association","volume":"57","author":"Bandela","year":"2026","journal-title":"Stroke"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"354906","DOI":"10.1155\/2014\/354906","article-title":"Pathophysiology of spasticity: Implications for neurorehabilitation","volume":"2014","author":"Trompetto","year":"2014","journal-title":"BioMed Res. Int."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"108287","DOI":"10.1016\/j.toxicon.2025.108287","article-title":"A practical booklet for ultrasound-guided botulinum toxin injections","volume":"256","author":"Carda","year":"2025","journal-title":"Toxicon"},{"key":"ref_8","first-page":"12397","article-title":"Assessing muscle architecture with ultrasound: Implications for spasticity","volume":"34","author":"Boissonnault","year":"2024","journal-title":"Eur. J. Transl. Myol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"656","DOI":"10.1016\/S0022-3476(82)80286-2","article-title":"Ultrasound imaging in the diagnosis of muscle disease","volume":"101","author":"Heckmatt","year":"1982","journal-title":"J. Pediatr."},{"key":"ref_10","first-page":"100071","article-title":"Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes with Ultrasound in Spasticity","volume":"2","author":"Moreta","year":"2020","journal-title":"Arch. Rehabil. Res. Clin. Transl."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1016\/j.ultrasmedbio.2016.12.008","article-title":"Evaluation of post-stroke spastic muscle stiffness using shear wave ultrasound elastography","volume":"43","author":"Wu","year":"2017","journal-title":"Ultrasound Med. Biol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1179573521996141","DOI":"10.1177\/1179573521996141","article-title":"Quantitative ultrasound to assess skeletal muscles in post-stroke spasticity","volume":"13","author":"Tran","year":"2021","journal-title":"J. Cent. Nerv. Syst. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1002\/mus.25716","article-title":"Two-dimensional and shear wave elastography ultrasound: A reliable method to analyse spastic muscles?","volume":"57","author":"Mathevon","year":"2018","journal-title":"Muscle Nerv."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1097\/PHM.0000000000002660","article-title":"Ultrasound assessment of muscle and fascia properties and the effects of spasticity and botulinum toxin injections in chronic stroke survivors","volume":"104","author":"Magat","year":"2025","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Reebye, R., Jacinto, L.J., Balbert, A., Biering-Soerensen, B., Carda, S., Draulans, N., Molteni, F., O\u2019Dell, M.W., Picelli, A., and Santamato, A. (2024). Multimodal therapy and use of adjunctive therapies to BoNT-A in spasticity management. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1432330"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"326","DOI":"10.5535\/arm.23108","article-title":"Post-stroke spastic movement disorder and botulinum toxin A therapy: Early detection and early injection","volume":"47","author":"Wissel","year":"2023","journal-title":"Ann. Rehabil. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"jrm00134","DOI":"10.2340\/16501977-2753","article-title":"A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A","volume":"53","author":"Francisco","year":"2021","journal-title":"J. Rehabil. Med."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Lee, J., and Yang, S.N. (2024). Effectiveness of extracorporeal shock wave therapy after botulinum toxin injection for post-stroke upper extremity spasticity: A randomized controlled study. Toxins, 16.","DOI":"10.3390\/toxins16040197"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Mihai, E.E., Dumitru, L., Mihai, I.V., and Berteanu, M. (2020). Long-term efficacy of extracorporeal shock wave therapy on lower limb post-stroke spasticity: A systematic review and meta-analysis. J. Clin. Med., 10.","DOI":"10.3390\/jcm10010086"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"11607","DOI":"10.4081\/ejtm.2023.11607","article-title":"Conventional physical therapy combined with extracorporeal shock wave therapy leads to positive effects on spasticity in stroke survivors","volume":"33","author":"Mihai","year":"2023","journal-title":"Eur. J. Transl. Myol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"565","DOI":"10.23736\/S1973-9087.22.07136-2","article-title":"Extracorporeal shock wave therapy and botulinum toxin for spasticity: A systematic review","volume":"58","author":"Mihai","year":"2022","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Picelli, A., Filippetti, M., Sandrini, G., Tassorelli, C., De Icco, R., Smania, N., and Tamburin, S. (2021). Electrical stimulation of injected muscles to boost botulinum toxin effect on spasticity. Toxins, 13.","DOI":"10.3390\/toxins13050303"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"101222","DOI":"10.1016\/j.eclinm.2021.101222","article-title":"Botulinum toxin vs shockwave therapy for post-stroke spasticity","volume":"43","author":"Hsu","year":"2021","journal-title":"EClinicalMedicine"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1016\/j.ultrasmedbio.2012.09.019","article-title":"Shock wave therapy vs electrical stimulation after BoNT-A","volume":"39","author":"Santamato","year":"2013","journal-title":"Ultrasound Med. Biol."},{"key":"ref_25","first-page":"226","article-title":"Shock waves enhance botulinum toxin effect in spasticity","volume":"104","author":"Saavedra","year":"2025","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2197","DOI":"10.1161\/STROKEAHA.115.009633","article-title":"Effects of electrical stimulation in spastic muscles after stroke","volume":"46","author":"Stein","year":"2015","journal-title":"Stroke"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"100876","DOI":"10.1016\/j.rh.2024.100876","article-title":"Ultrasound-guided botulinum toxin injections in post-stroke spasticity","volume":"59","author":"Ayyildiz","year":"2025","journal-title":"Rehabilitaci\u00f3n"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"jrm11963","DOI":"10.2340\/jrm.v55.11963","article-title":"Ultrasound- vs electrical-stimulation-guided botulinum toxin injections","volume":"55","author":"Hauret","year":"2023","journal-title":"J. Rehabil. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"108350","DOI":"10.1016\/j.toxicon.2025.108350","article-title":"Muscle physiology in spasticity and stiffness","volume":"259","author":"Raghavan","year":"2025","journal-title":"Toxicon"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1097\/PHM.0000000000001064","article-title":"The Effects of Electrical Stimulation Parameters in Managing Spasticity After Spinal Cord Injury: A Systematic Review","volume":"98","author":"Bekhet","year":"2019","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_31","first-page":"103","article-title":"Use of surface EMG for evaluation of upper limb spasticity during botulinum toxin therapy in stroke patients","volume":"25","author":"Albani","year":"2010","journal-title":"Funct. Neurol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"107418","DOI":"10.1016\/j.jstrokecerebrovasdis.2023.107418","article-title":"Somatosensory evoked potentials amplitude is enhanced after non-invasive brain stimulation in chronic ischemic stroke: Preliminary results from a randomised control trial","volume":"33","author":"Jayan","year":"2024","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1177\/0269215515593783","article-title":"Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity","volume":"30","author":"Mills","year":"2016","journal-title":"Clin. Rehabil."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/j.rehab.2018.08.004","article-title":"Adjuvant treatments associated with botulinum toxin injection for managing spasticity: An overview of the literature","volume":"62","author":"Picelli","year":"2019","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"101544","DOI":"10.1016\/j.rehab.2021.101544","article-title":"Adjunct therapies after botulinum toxin injections in spastic adults. Systematic review and SOFMER recommendations","volume":"65","author":"Allart","year":"2022","journal-title":"Ann. Phys. Rehabil. Med."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/8\/1271\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T08:26:18Z","timestamp":1785831978000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/8\/1271"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,31]]},"references-count":35,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["life16081271"],"URL":"https:\/\/doi.org\/10.3390\/life16081271","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,31]]}}}