Table 1.

Table of studies.

Authors	Types of Studies	RCTs/ Population	Population	Interventions	Parameters	Control	Outcome Measures	Future Studies/ Limitation
1. Stretching exercise
Gomez et al., 2021 [13]	SR and meta- analysis	8 RCTs included in the SR; 6 RCTs included in the meta- analysis (332 patients)	Chronic stroke (3–6 months)	Passive static/ dynamic stretching by PT, self-stretching	Varied greatly, but none of them exceed 60 min/ session	No treatment	MAS p = 0.45, I2 = 92%	Larger sample size and optimal protocol
2. Static stretching with positioning orthoses
Salazar et al., 2018 [14]	SR and meta- analysis	3 RCTs for spasticity outcome (57 patients)	Chronic stroke	Static stretching with wrist devices	6–7 days/week, 20–45 min/day (separated by 2–3 time/day), 3–4 weeks	No treatment	MAS p < 0.01, I2 = 82%	Larger sample size
3. Transcutaneous electrical nerve stimulation (TENS)
Mahmood et al., 2018 [15]	SR and meta- analysis	15 RCTs included in the SR; 7 RCTs Included in the meta- analysis (427 patients)	Chronic stroke	TENS	High frequency (100 Hz), duration > 30 min/session, electrodes placement along the nerve/ muscle belly, intensity twice of the sensory threshold, and treatment duration > 2 weeks	No treatment, or placebo- controlled interventions, or active controls, or PT	MAS p = 0.001, I2 = 17%	Focusing on effect in UE, duration of efficacy, and effect of low TENS
4. Extracorporeal shock wave therapy (ESWT)
Zhang et al., 2022 [16]	SR and meta- analysis	42 RCTs Included in the SR; 34 RCTs Included in the meta-analysis (1973 patients)	Upper motor neuron injury (29 studies focused on stroke)	ESWT	Radial ESWT >2 sessions	Sham ESWT/ conventional RT	MAS p < 0.0001, I2 = 78%	Focusing on the duration of efficacy, dose response relationship, mechanism
5. Repetitive peripheral magnetic stimulation (rPMS)
Pan et al., 2022 [17]	SR and meta- analysis	8 RCTs included in the SR; 6 RCTs Included in the meta-analysis (297 patients)	Spastic paralysis patients (170 chronic stroke)	rPMS	5/25 Hz of frequency, 3–30 min/ session, and round/ figure of eight coil types	Sham rPMS and/or PT, and PT	AS, MAS, MTS, and FMA	Focusing on the duration of efficacy, with larger sample size, and optimal protocol
6. Non-invasive brain stimulation (NIBS)
Wang et al., 2022 [18]	SR and meta- analysis	14 RCTs (232 patients on TMS, and 345 patients on tDCS)	Stroke patients	11 RCTs on TMS	Low frequency at unaffected hemisphere	Sham TMS, Sham TMS plus PT, Sham TMS plus RT	MAS in UE p < 0.00001, I2 = 3%	Further study in LE spasticity, mechanism, and the duration of efficacy
				7 RCTs on tDCS	Anodal stimulation at affected hemisphere, 0.7 mA or 1.2 mA	Sham tDCS, Sham tDCS plus PT, Sham tDCS plus VR	MAS in UE p = 0.003, I2 = 78%
7. Botulinum toxin A (BoNT-A) injection
7.1 In the upper and lower extremities
Schnitzler et al., 2022 [19]	SR	49 primary studies	Spasticity of any Etiology (38 studies in stroke/ brain injury)	BoNT-A injection	AboBoNT-A	Placebo/ control or another BoNT-A treatment	AboBoNT-A dose given per muscle in clinical practice varies considerably, with only a slight trend toward a relationship between dose and muscle volume	-
7.2 In the upper extremities
Sun et al., 2019 [20]	meta- analysis	27 RCTs (2793 patients) (16 trials UE; 12 trials of muscle tone in UE)	Stroke patients	BoNT- A injection	AboBoNT-A/ OnaBoNT-A/ IncoBoNT-A	Placebo	Muscle tone p < 0.001, I2 = 52.1%	-
Andringa et al., 2019 [21]	SR and meta- analysis	40 RCTs (2718 patients)	Stroke patients	UE BoNT-A injection		Placebo and/or PT	MAS and AS	-
7.3 In the lower extremities
Doan et al., 2021 [22]	SR and meta- analysis	12 RCTs included in SR, 9 RCTs included in Meta- Analysis (1601patients)	PSS in LE	BoNT-A Injection in LE	300 units of OnaBoNT-A and 1000 units of AboBoNT-A	Placebo/ dose- ranging	MAS, AS at week 4th, 8th, and 12th	Further studies on functional improvement
8. Dry needling (DN)
Fernández et al., 2021 [23]	SR and meta- analysis	7 RCTs (83 patients)	Stroke patients	DN	-	RT/ sham DN/ non-TrP DN	MAS, MMAS p = 0.0007, I2 = 66%: UE p = 0.18, LE p < 0.0001	Larger sample size and examining the long-term effect
9. Intrathecal baclofen (ITB)
Creamer et al., 2018 [24,25]	Multi- center phase 4 RCT	60 patients (ITB: 31; control: 29)	PSS in ≥2 extremities and ASS of ≥3 in ≥2 affected LE	ITB	-	CMM with oral antispastic drugs	ASS in LE, NRS, and quality of life	Larger sample sizes and longer follow-up
10. Whole-body vibration (WBV)
Zhang et al., 2023 [26]	SR and meta- analysis	11 RCTs (475 patients)	Stroke patients	WBV or PT with WBV	Variable	Sham WBV or PT	MAS	Focusing on the duration of efficacy, severe spasticity
11. Localized muscle vibration (LMV)
Avvantaggiato et al., 2021 [27]	SR and meta- analysis	14 RCTs (425 patients)	Stroke patients	LMV plus PT	Variable from frequency 30, 80, 90, 91, 100, 120, and 300 Hz; amplitude 0.01, 0.2–0.5, 1, and 2 mm; duration 5, 20, 30, and 60 min	PT/sham plus PT	Neurophysiological parameters (TMS, ENG, and EMG), MAS (elbow: p = 0.001, I2 = 0%; wrist: p = 0.04, I2 = 36%; shoulder: p = 0.26, I2 = 0%) Functional scales	Larger size of homogeneous patients (shared methodology), on LE

SR: systematic review; RCTs: randomized controlled trials; PT: physical therapy; MAS: Modified Ashworth Scale; TENS: transcutaneous electrical nerve stimulation; ESWT: extracorporeal shock wave therapy; rPMS: repetitive peripheral magnetic stimulation; AS: Ashworth Scale; MTS: Modified Tardieu Scale; FMA: Fugl–Meyer Assessment; NIBS: non-invasive brain stimulation; TMS: transcranial magnetic stimulation; tDCS: transcranial direct current stimulation; UE: upper extremities; LE: lower extremities; BoNT-A inj.: botulinum toxin A injection; TrP: triggered point; DN: dry needling; MMAS: Modified Modified Ashworth Scale; RT: rehabilitation therapy; MA: manual acupuncture; ASS: Ashworth Scale Score; ITB: intrathecal baclofen; CMM: conventional medical management; NRS: numeric rating scale; WBV: whole-body vibration; LMV: localized muscle vibration, ENG: electroneurography; and EMG: electromyography.