Musculoskeletal disorders following stroke - An explainer for Africans


By: Rukhsar Jabbar. M.Sc. Physiotherapy. Freelance Health Writer and Datelinehealth Africa (DLHA) volunteer. Medical review and editorial support provided by the DLHA Team.


Elderly man being assisted to walk on walker by physiotherapist

Unrecognised elderly man being assisted to walk with a walker by a physiotherapist.

Image by: Drazen Zigic on Freepik. Click on image to enlarge.





Stroke is the world's second greatest cause of mortality, with permanent disability affecting up to half of survivors. Long-term disability induced by stroke is mostly related to motor function impairment, which is determined by both primary and subsequent modifications following stroke.


Those who have survived strokes must deal with its long-term consequences, which include permanent functional impairments that decrease autonomy in daily tasks. Common symptoms in survivors of stroke are weakness, hypotrophy, fatigability, and impaired motor control, which come from a blend of denervation, inactivity, remodeling, and spasticity. [1] 


This article aims to address the complexities of musculoskeletal disorders that may arise following a stroke, offering clear and accessible information to empower Africans with knowledge about the impact of stroke on the body. 



Prevalence of stroke in Africa


In 1991, a study of hospital patients evaluated the yearly stroke incidence in Harare, Zimbabwe, at 31 per 100,000 people.


The largest community prevalence study on stroke in Africa was conducted in 1994 in Tanzania's rural Hai area, and it found an age-standardized incidence rate of 154 per 100,000 in men over 15 and 114 per 100,000 in women over 15 years of age. Evidence suggests that the case fatality rate for strokes may be greater in regions of Africa than in other parts of the world. [2]



Understanding Stroke


Definition and types of strokes 


A stroke can develop when blood flow to the brain is disrupted or there is unexpected bleeding in the brain. The National Heart, Lung, and Blood Institute (NIH) explains that strokes come in two main types: ischemic strokes and hemorrhagic strokes.


An ischemic stroke occurs when blood flow to the brain is impeded. The brain cannot receive oxygen and nutrients from the bloodstream. Without oxygen and nourishment, a brain cell begins to die within minutes. A hemorrhagic stroke is caused by abrupt bleeding in the brain. [3]


Just fewer than 90% of strokes are caused by clogged blood vessels (ischemic), with the remainder caused by internal bleeding (hemorrhagic). Haemorrhagic strokes are further characterized according to where in the brain an obstruction or bleeding occurs.[3]


There are two distinct types of haemorrhagic stroke that can occur:

  • Intracerebral haemorrhage
  • Subarachnoid haemorrhage


Intracerebral haemorrhage: The most frequent kind of hemorrhagic stroke is called an intracerebral hemorrhagic stroke (ICH), in which a blood vessel inside the brain bursts and begins to hemorrhage. The cause of almost two-thirds of haemorrhagic strokes is hypertension.


Subarachnoid haemorrhagic stroke (SAH): This is bleeding into the subarachnoid space caused by a rupture of the blood vessels outside or on the surface of the brain. Among other things, the fluid in this area serves to cushion the brain's jelly-like structure from the bony skull. The brain tissue beneath is suddenly under pressure when there is a bleed into the subarachnoid space.


A stroke constitutes a medical emergency. A stroke can result in permanent brain damage, long-term disability, and even death. [3] 


For more easy-to-understand articles, in-depth research studies and expert opinions on stroke, check out these related articles.

Stroke In Africa: What You Need To Know

Stroke Treatment in Africa



Importance of understanding post-stroke musculoskeletal (MSK) disorders in the African context


Following a stroke, the time spent in bed throughout the day exceeds 50%. Thus, stroke damage and restricted mobility would combine to cause a loss in muscle tissue in the weakened (paretic) muscles and, to a lesser extent, the non-paretic muscles.


After a stroke, muscle fibers experience multiple changes, including a shift in pennation angle, a drop in fibre length, and a reduction in lean muscle mass. [4]  The mechanical properties of muscles play a vital part in force generation; for example, an order from the nervous system that activates a muscle would generate varied degrees of force in accordance with the state of that muscle. [4]


A basic knowledge of how MSK disorders occur following a stroke is therefore very important for post-stroke care and recovery for both stroke survivors and healthcare professionals.



Types of post-stroke musculoskeletal (MSK) disorders 


MSK difficulties after a stroke almost often affect the weak, parietic, or hemiplegic side and might not become apparent for weeks or months. Patients experience pain and discomfort following stroke [5] and major complications are discussed further.


  • Spasticity


A stroke can affect the nerves that control your muscles. This can cause muscles to contract for extended periods or to harden, a condition known in medical lingo as spasticity or hypertonicity.


Your muscle tone is a measure of resistance or tension in the muscles that allows you to move and remain in position. Muscles never fully relax. They maintain some resistance even when not in use and appear springy to the touch.[6]


Spasticity causes muscles to become more toned and tighter. People with spasticity may struggle to use their arms or hands, or they may notice that stiff leg muscles interfere with their walking. Spasticity affects around one-quarter of stroke survivors.


Spasticity can emerge within a week of a stroke or much later. It can be managed to help avoid contractures.[6]


  • Contractures


Spasticity can occasionally result in a permanent shortening of the muscles, known as contracture. If this occurs, your joint may not completely bend or straighten, because the muscles are unable to stretch to their full extent.


If you have a contracture, your arm or hand may remain bent. It may make it difficult to get dressed. If you have a contracture in your lower extremity, it may be difficult to walk. A contracture's effect is determined by several elements, including the affected joint and the degree of severity of the associated contracture.[6]


  • Pain


Pain is a typical condition after a stroke, and it can have a variety of causes. Some persons experience spasticity, or muscle stiffness, which can be painful. Shoulder pain can be caused by muscle rigidity or weakness, resulting in a partial dislocation.


Some patients may experience uncomfortable or strange feelings such as tingling, freezing, or burning, which could be the result of nervous system injury. Headaches are typical after a stroke.[6]


  • Muscle weakness


If your muscles are weak following a stroke, you may have difficulty sitting, standing, walking, using your arms, or holding objects.


Hemiparesis is marked by the weakening of one side of the body whereas hemiplegia involves a form of paralysis that impacts one side of the body.


If you have weakness or paralysis, you may require assistance with daily activities. For example, hand and arm weakness might make it difficult to pick up and hold objects. If your leg is weak, you may be more prone to slipping, tripping, or falling. For example, when you put weight on your ankle, it may flip around. Muscle weakness on one side might also make it difficult to coordinate motions.[6]


  • Foot drop


Foot drop can be caused by weakness in the muscles of the foot and ankle, making it difficult to lift your toes and the front half of your foot. This causes your toes to catch on the ground while walking. To compensate for the weakness in your ankle, you might raise your foot higher than usual or swing your leg to the side. Foot drop can cause problems with walking and a higher probability of falling. [6]



Role of rehabilitation following post-stroke MSK disorders 


Rehabilitation begins while you are in the hospital and should continue for as long as you need it after leaving. Rehabilitation should have defined goals that you and the therapist agree on. If you experience physical symptoms such as movement difficulty, balance issues, or sensory disturbances, you might be offered physiotherapy or occupational therapy. If you have movement limitations, physiotherapy should continue until you can function independently or can move with the support of others. [6]


Your rehabilitation treatment should be provided by a single healthcare practitioner or a team. It can be carried out one-on-one or in groups. You may have exercises to practice on your own time. Practicing tasks during therapy sessions can help you achieve your objectives. You could seek support and encouragement from family and friends. Try to incorporate movement and exercise into your daily activities.


If you require assistance with a physical symptom of a stroke after you leave the hospital, contact your primary care provider or General Practitioner (GP). They can provide advice and direct you to professionals like a physiotherapist or occupational therapist.


Patients with strokes frequently experience a variety of symptoms that worsen their quality of life. One vital thing stroke sufferers can do to enhance their health is exercise. 


Regular exercise lowers your initial risk of stroke as well as other conditions like high blood pressure, diabetes, etc. By elevating your mood and reducing the symptoms of despair and anxiety, it also enhances your physical and mental well-being. 


Patients who have had a stroke should be aware that exercise can help them regain their quality of life and improve their physical limitations. Patients who have had a stroke frequently experience pain, exhaustion, and brain damage. Exercise can assist you in regaining your strength as well as enhancing your balance, coordination, and joint mobility. 


Exercises that target the damaged body part are useful in aiding in the rehabilitation from stroke. 


Post-stroke symptoms, such as muscle weakness and restricted upper and lower body motions, are common in stroke patients. This results from damage to the area of the brain responsible for controlling the muscles surrounding the hand, wrist, and shoulder following a stroke. To help recover the muscle's strength, balance, coordination, and functional independence, exercise is recommended.


Some of the exercises advised include:


Exercises that put you at risk of injury, such as weight training, running, and jumping rope, should be avoided.


To assist you in establishing a customized exercise program that is safe and effective to help improve your health, it is essential to speak with your physical therapist if you are unclear about which exercises to perform. 



How rehabilitation works to reduce MSK disorders


  • Spasticity and Hypertonicity 


Spasticity symptoms can occur in up to 60% of stroke patients. Spasticity is excessive, inappropriate, and involuntary muscular activity that causes stiffness, loss of movement, and pain. At worst, it causes a fixed deformity termed as a contracture, which can lead to the formation of pressure sores .[5]  Regular, appropriate and tailored   exercises help to keep affected muscles supple and reduce the impact of spasticity.


Conservative treatment for contractures includes physiotherapy (passive range of motion exercises), splinting, and appropriate limb posture. Pharmacological therapy to treat spasticity in stroke patients includes both systemic and local medications. Drug treatment should not be utilized alone, but in conjunction with physiotherapy and positioning/active splinting. [5]


Systemic spasticity treatments comprise oral baclofen, tizanidine, dantrolene, along with diazepam. Botulinum toxin is an effective treatment for spasticity in a restricted set of people. Botulinum toxin is a targeted therapy, as opposed to systemic antispasticity medicines, which are nonselective and often linked with broad weakness and functional loss.


Surgical treatment is rarely performed, although it may be necessary as a last option to ensure good seating and fitting for orthoses, as well as suitable hygiene. [6] 


  • Hemiplegic shoulder pain 


Hemiplegic shoulder pain (HSP) is common (9% - 40% of hemiplegic stroke cases) and usually appears 2-3 months after the stroke begins. HSP can be divided into four types: 

(i) Joint pain triggered by a misaligned joint causing sharp pain on activity (active or passive); 

(ii) Hyperactive or spastic muscle pain (deep pulling pain on activity);

 (iii) Diffuse pain coming from altered sensation resulting from stroke (constant ache in the area of the shoulder); and

 (iv) Reflex sympathetic dystrophy affecting the entire limb and shoulder. 


HSP can be avoided by paying attention to handling and positioning, particularly in patients with flaccid arms early in stroke recovery. Simple analgesics or particular anti-spasticity medications, such as baclofen, may be all that is needed for treatment. Other invasive treatments may be required. Your physiotherapist would work with you to provide the best care for your condition.


  • Wrist and hand flexion 


Wrist and Hand Flexion contractures may occur in hemiplegic wrists and hands. A permanent flexion contracture of the hand prevents the restoration of hand function. It can be uncomfortable and sometimes unattractive. Prevention through frequent range of motion exercises and positioning splints is the key to management. Splints should maintain a modest stretch on flexor muscles, maintaining the wrist in 20-30° of extension, and resist spasticity. [5]      





Musculoskeletal (MSK) disorders are common complications of stroke. They may occur immediately after a stroke or appear several months into stroke recovery.


Post stroke MSK disorders are commonly characterised by spasticity (increased tone in muscles) and weakness of part or whole of one side of the body, contracture, pain and disuse muscle wasting in the long term.


The treatment of MSK disorders post-stroke necessitates a multidisciplinary strategy that includes a variety of healthcare specialists and therapies, ranging from pharmaceutical therapy to surgical procedures and non-intrusive rehabilitation techniques. Orthopedic rehabilitation plays a critical role in promoting functional recovery and preventing impairment.[7]




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2. Akinyemi RO, Ovbiagele B, Adeniji OA, Sarfo FS, Abd-Allah F, Adoukonou T, Ogah OS, Naidoo P, Damasceno A, Walker RW, Ogunniyi A, Kalaria RN, Owolabi MO. Stroke in Africa: profile, progress, prospects and priorities. Nat Rev Neurol. 2021;17(10):634–56. doi: 10.1038/s41582-021-00542-4. Available from:

3. Samuel. O. Stroke in Africa: What you  need to know. Datelinehealth Africa. [Internet. October 5, 2023]. Cited 2024 Jan. 31. Available from:

4. Gray V, Rice CL, Garland SJ. Factors that influence muscle weakness following stroke and their clinical implications: a critical review. Physiotherapy Canada. 2012 Oct;64(4):415-26.doi: 10.3138/ptc.2011-03. Available from:

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Published: February 5, 2024

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