What are the medications used to manage spasticity?

Medications for Spasticity Management

The first-line oral medications for spasticity management are tizanidine, baclofen, and dantrolene, with botulinum toxin injections recommended for focal spasticity, and intrathecal baclofen reserved for severe cases unresponsive to other treatments. 1

Stepwise Approach to Spasticity Management

Spasticity, defined as velocity-dependent hyperactivity of tonic stretch reflexes, affects approximately 25-43% of stroke patients within the first year and can significantly impact mortality, morbidity, and quality of life through pain, contractures, and functional limitations 1.

First-Line Non-Pharmacological Interventions

• Antispastic positioning
• Range of motion exercises
• Stretching
• Splinting
• Serial casting

Oral Medications

1. Tizanidine

   • FDA-approved for spasticity management
   • Short-acting, best for when relief is most important for specific activities 2
   • Shown efficacy in chronic stroke patients with improvement in spasticity and pain without loss of motor strength 1
   • Fewer cognitive side effects than other options

2. Oral Baclofen

   • FDA-approved for spasticity
   • May cause significant sedation
   • Less impact on spasticity in stroke compared to other conditions 1
   • Side effects include sedation, excessive weakness, dizziness, and mental confusion 3, 4
   • Approximately 25-30% of patients fail to respond to oral baclofen 5

3. Dantrolene

   • Acts directly on muscle
   • Limited trial data supporting use in stroke 1
   • Benefit of fewer cognitive side effects

CAUTION: Diazepam and other benzodiazepines are contraindicated during stroke recovery due to possible deleterious effects on recovery and sedation side effects 1

Injectable Treatments for Focal Spasticity

• Botulinum Toxin

  • Strong evidence for focal upper and lower limb spasticity 1
  • Recommended for disabling or painful spasticity or when spasticity affects skin hygiene or function 1
  • Class I, Level A evidence for reducing spasticity and improving range of motion 1

• Phenol/Alcohol Nerve Blocks

  • Alternative for selected patients with disabling or painful spasticity 1

Advanced Interventions for Severe Spasticity

• Intrathecal Baclofen

  • Reserved for severe spastic hypertonia unresponsive to other treatments 1, 6
  • Can be considered as early as 3-6 months after stroke for refractory cases 6
  • Delivers baclofen directly to CSF at concentrations less than 1/100th of oral doses 5
  • Requires surgical implantation of pump and reservoir
  • Risk of withdrawal syndrome if delivery is interrupted 6

• Neurosurgical Procedures

  • Selective dorsal rhizotomy or dorsal root entry zone lesions
  • Significant risks involved
  • Limited clinical trial evidence 1

Special Considerations

• Monitoring: Regular assessment of efficacy, side effects, and functional outcomes is essential
• Side Effect Management: Sedation is common with oral medications (10-75% incidence) 4, 7
• Withdrawal Risk: Abrupt cessation of baclofen (especially intrathecal) can lead to severe withdrawal syndrome 6
• Functional Impact: Treatment should focus on improving pain, skin hygiene, and function rather than just reducing muscle tone 1

Algorithm for Medication Selection

1. For generalized spasticity:

   • Start with tizanidine if short-duration relief is needed for specific activities
   • Consider baclofen for more continuous relief, starting at low doses and titrating up
   • Use dantrolene when cognitive side effects must be minimized

2. For focal spasticity:

   • Botulinum toxin injections are first-line therapy
   • Consider phenol/alcohol blocks as alternatives

3. For severe, refractory spasticity:

   • Consider intrathecal baclofen when oral medications fail or cause intolerable side effects
   • Reserve neurosurgical procedures for the most resistant cases

By following this evidence-based approach to medication selection for spasticity management, clinicians can optimize outcomes while minimizing adverse effects that could negatively impact mortality, morbidity, and quality of life.