Botulinum toxin type a within function-oriented management of post-stroke spasticity: a narrative review

Post-stroke spasticity (PSS) is a heterogeneous complication of stroke that affects motor recovery, care needs, pain, positioning, and participation in daily life. Current management frameworks commonly stratify patients by time since stroke, but disease duration alone does not capture differences in neural mechanisms, residual voluntary control, functional priorities, or response to intervention. This narrative review searched PubMed, the Cochrane Library, and Wanfang databases from inception to May 2026, prioritizing randomized controlled trials, prospective cohort studies, systematic reviews, real-world studies, Goal Attainment Scaling research, the Upper Limb International Spasticity cohort series, best-practice guidance, and clinical trials including BEST and InTENSE. We synthesize evidence that PSS heterogeneity can be understood across central and peripheral mechanisms, temporal trajectories, and active versus passive functional consequences. Available studies suggest that active and passive functional goals differ in baseline functional profiles, outcome assessment, treatment response, and intervention requirements. However, patients sharing a functional goal type may still differ in residual voluntary control, neural and non-neural contributors to movement restriction, pain, mobility, and care dependency. Botulinum toxin type A is well aligned with focal tone reduction and passive goals, including pain relief, hygiene, and limb positioning. It may also support contracture-prevention strategies when modifiable neural muscle overactivity remains, whereas active functional gains usually require preserved motor potential and integration with task-oriented training, rehabilitation, and adjunctive modalities. We propose that functional goal type should complement time-based staging as a decision dimension rather than serve as a complete clinical phenotype. This combined framework may better align patient selection, intervention matching, outcome assessment, and longitudinal treatment planning. Prospective goal-stratified studies and standardized assessment tools are needed to test its clinical utility.