From the Guidelines
The treatment of post-stroke spasticity should involve a multifaceted approach combining physical therapy, oral medications, injectable treatments, and sometimes surgical interventions, with botulinum toxin injections being a highly effective option for focal spasticity, as recommended by the American Heart Association/American Stroke Association guidelines 1. The goal of treatment is to reduce abnormal muscle tone caused by upper motor neuron damage, which disrupts the balance between excitatory and inhibitory signals to muscles, ultimately improving function and preventing complications like pain and contractures. Some key considerations in the treatment of post-stroke spasticity include:
- Physical therapy forms the foundation of treatment, including stretching exercises, range-of-motion activities, and positioning techniques to maintain muscle length and prevent contractures.
- First-line oral medications include baclofen, tizanidine, and dantrolene, with dosages adjusted based on patient tolerance and response.
- For focal spasticity, botulinum toxin injections (Botox 100-400 units or Dysport 500-1500 units) are highly effective, with effects lasting 3-4 months before requiring repeat treatment, as supported by the guidelines 1.
- Intrathecal baclofen therapy via an implanted pump may be considered for severe, generalized spasticity, starting with a test dose of 50-100mcg followed by titration to effect, as recommended by the guidelines 1. Treatment should begin early after stroke and be tailored to the patient's specific pattern of spasticity, functional goals, and tolerance of side effects, with the aim of improving quality of life and reducing caregiver burden, as highlighted in the guidelines 1. It is also important to note that the cost of treating spasticity may not reduce the overall cost of stroke-related care, but it can improve patient outcomes and reduce activity limitations associated with hygiene, dressing, and pain, as discussed in the guidelines 1. Overall, a comprehensive treatment approach that incorporates physical therapy, oral medications, injectable treatments, and sometimes surgical interventions can help improve outcomes and quality of life for patients with post-stroke spasticity, as supported by the guidelines 1.
From the Research
Treatment Options for Post-Stroke Spasticity
- Intrathecal baclofen (ITB) is an effective treatment for managing patients with severe post-stroke spasticity, as it has been shown to improve pain and quality of life in these patients 2.
- General pharmacological treatments such as baclofen, tizanidine, and dantrolene are available for post-stroke spasticity, but are limited by adverse events and lack of evidence of functional benefit 3.
- Oral baclofen can be effective in reducing spasticity in some patients, but the responder rate is low, and a short-term trial with quantitative and electrophysiological assessments is recommended 4.
- Physical therapy interventions such as transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training can be effective in managing post-stroke spasticity, with moderate quality evidence supporting their use 5.
- Botulinum toxin A is a effective treatment for post-stroke spasticity, and its use can be optimized with adjunctive therapies and a multidisciplinary approach 6.
Pharmacological Interventions
- Baclofen is a commonly used medication for post-stroke spasticity, and can be administered orally or intrathecally 2, 4.
- Tizanidine and dantrolene are also used to treat post-stroke spasticity, but their use is limited by adverse events and lack of evidence of functional benefit 3.
- Botulinum toxin A is a effective treatment for post-stroke spasticity, and can be used in conjunction with other therapies to optimize its benefits 6.
Non-Pharmacological Interventions
- Physical therapy interventions such as transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training can be effective in managing post-stroke spasticity 5.
- A multidisciplinary approach to treatment, including the use of adjunctive therapies, can help to optimize the benefits of botulinum toxin A in patients with post-stroke spasticity 6.