What is the treatment for spasticity (increased muscle tone)?

From the Guidelines

Spasticity should be treated with botulinum toxin injections for patients with focal spasticity, as evidenced by the most recent and highest quality study 1. The treatment of spasticity is crucial for improving mobility and preventing complications like contractures, pain, and skin breakdown.

Treatment Options

• Physical therapy with stretching exercises to maintain range of motion
• Oral medications such as baclofen (starting at 5mg three times daily, gradually increasing to 20-25mg three times daily as needed) or tizanidine (2-4mg initially, increasing to 8mg three times daily if necessary)
• Botulinum toxin injections (Botox) for localized spasticity, which has been shown to be effective in reducing spasticity and improving functional outcomes 1
• Intrathecal baclofen therapy via an implanted pump or surgical interventions like selective dorsal rhizotomy for severe cases

Key Considerations

• Daily stretching routines, proper positioning, and assistive devices are crucial for managing symptoms
• Treatment should be individualized based on the severity of symptoms, functional goals, and underlying cause of the spasticity
• The use of botulinum toxin has been supported by recent evidence 1, which suggests that it may not have a dramatically different place in therapy from oral antispasmodics based on efficacy alone

Recent Evidence

• A small RCT compared the efficacy of botulinum toxin versus oral baclofen on multiple upper- and lower-limb spasticity outcomes, and found no significant difference between the two treatments except for ankle spasticity, which favored botulinum toxin 1
• The 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines support the use of botulinum toxin for patients with focal spasticity depending on patient characteristics and preferences 1

From the FDA Drug Label

Tizanidine’s capacity to reduce increased muscle tone associated with spasticity was demonstrated in two adequate and well controlled studies in patients with multiple sclerosis or spinal cord injury. A statistically significant reduction of the Ashworth score for tizanidine compared to placebo was detected at 1,2 and 3 hours after treatment. The greatest reduction in muscle tone was 1 to 2 hours after treatment At endpoint (the protocol-specified time of outcome assessment), there was a statistically significant reduction in muscle tone and frequency of spasms in the tizanidine treated group compared to placebo

Tizanidine is effective in reducing spasticity. The drug has been shown to reduce muscle tone in patients with multiple sclerosis or spinal cord injury, with the greatest reduction in muscle tone occurring 1 to 2 hours after treatment 2. The reduction in muscle tone is correlated with plasma concentration, and the effect of the drug is dose-related 2. Key benefits of tizanidine include:

• Reduction in muscle tone
• Reduction in frequency of spasms
• Improvement in muscle tone is correlated with plasma concentration It is essential to note that tizanidine should be used with caution in certain patient populations, such as those with renal insufficiency 2.

From the Research

Definition and Management of Spasticity

• Spasticity is a common manifestation of many neurological conditions, including multiple sclerosis, stroke, cerebral palsy, traumatic brain injury, and spinal cord injuries 3.
• Management of spasticity seeks to reduce its burden on patients and to limit secondary complications, and may involve a team approach including the patient and caregivers, therapists, physicians, and surgeons 4.

Treatment Options for Spasticity

• Traditional therapy continues to dominate the therapy provided to patients who are living with spasticity, and may include physical and occupational therapy, oral medication, injections of botulinum toxin, use of an intrathecal baclofen pump, or surgery 4.
• Oral medications such as baclofen, tizanidine, and dantrolene may be effective in managing spasticity, but may have adverse effects such as muscle weakness, nausea, somnolence, and paraesthesia 5, 6.
• Intrathecal baclofen may be an effective alternative to oral baclofen, as it delivers the drug directly into the cerebrospinal fluid, bypassing the blood-brain barrier and minimizing drug-related side-effects 6.
• Focal injection of botulinum toxin, alcohol, or phenol may also be used to manage spasticity, particularly in patients with focal spasticity involving overactive muscle groups 4, 7.

Surgical Management of Spasticity

• Surgical management of spasticity may be necessary to improve quality of life and prevent complications, and may involve orthopaedic surgeons managing sequelae of spasticity such as joint contractures, hip dislocations, scoliosis, and deformed extremities 3.
• Surgical resection of selected dorsal roots of the spinal cord may also be used to manage spasticity, particularly in patients who have not responded to other treatments 7.