From the Guidelines
Hyperreflexia management should focus on treating the underlying cause and controlling symptoms, with options including physical therapy, baclofen, tizanidine, and other medications, as the most effective approach to reduce morbidity, mortality, and improve quality of life. When managing hyperreflexia, particularly in the context of spasticity, it is crucial to consider a stepwise approach, starting with the least-invasive modalities and progressing to more invasive ones, as suggested by the management of adult stroke rehabilitation care guideline 1. Key considerations include:
- Positioning, passive stretching, and range of motion exercises to provide relief and prevent contractures, which should be done several times daily in persons with spasticity 1.
- The use of FDA-approved oral medications such as tizanidine, baclofen, dantrolene, and diazepam for the treatment of spasticity, with tizanidine shown to have efficacy in chronic stroke patients with improvement in spasticity and pain without loss of motor strength 1.
- The potential benefits and limitations of each medication, including the risk of sedation with oral baclofen and the limited trial data supporting the use of dantrolene in stroke patients 1.
- The importance of individualizing treatment based on the patient's specific needs and response to therapy, as well as the potential need for more invasive interventions such as intrathecal baclofen pumps or botulinum toxin injections in severe cases. Overall, a comprehensive approach to managing hyperreflexia, taking into account the underlying cause, symptom control, and the potential benefits and risks of different treatment options, is essential to optimize outcomes and improve quality of life for patients.
From the Research
Management of Hyperreflexia
Hyperreflexia is a prevalent neurological condition characterized by excessive and exaggerated reflex responses to stimuli. The management of hyperreflexia can be challenging, but several treatment options are available.
- PAK1 Inhibition: A study published in 2 found that PAK1 inhibition with Romidepsin attenuates H-reflex hyperexcitability after spinal cord injury. The results showed that Romidepsin treatment reduced signs of hyperreflexia in comparison with control cohorts and in pre- and post-drug intervention in SCI animals.
- Autonomic Hyperreflexia Management: Autonomic hyperreflexia occurs in up to 85 percent of individuals with spinal cord injuries above the major splanchnic sympathetic outflow 3. The clinical features of autonomic hyperreflexia are due largely to reflex sympathetic adrenergic and cholinergic discharges with dysfunctional supraspinal regulatory control. Removal of the offending stimulus is important to restoring the autonomic nervous system to its baseline activity.
- Botulinum Toxin Injection: Intravesical botulinum toxin injection has been shown to be effective in managing autonomic dysreflexia in patients with chronic spinal cord injury 4, 5. The injection can help to suppress incontinence episodes and increase functional bladder capacity.
- Epidural Anesthesia: Epidural anesthesia can safely control autonomic hyperreflexia during labor and delivery in pregnant paraplegic patients 6. However, it is difficult to determine the dermatomal spread of epidural anesthesia by the usual methods in spinal cord impaired patients.
Treatment Options
The treatment options for hyperreflexia depend on the underlying cause and severity of the condition. Some of the treatment options include:
- Medications to reduce spasticity and hyperreflexia
- Physical therapy to improve mobility and reduce muscle spasms
- Botulinum toxin injections to manage autonomic dysreflexia
- Epidural anesthesia to control autonomic hyperreflexia during labor and delivery
- PAK1 inhibition with Romidepsin to attenuate H-reflex hyperexcitability after spinal cord injury.