What is the best approach to manage spasticity post-stroke?

Management of Post-Stroke Spasticity

Spasticity after stroke should be treated with a stepwise approach, beginning with physical therapy interventions and oral medications like tizanidine or baclofen, progressing to more invasive options like botulinum toxin injections or intrathecal baclofen for refractory cases. 1

First-Line Interventions

Physical Therapy Approaches

• Positioning, passive stretching, and range-of-motion exercises should be performed several times daily 2, 1
• While widely used, recent evidence suggests limited conclusive evidence on the effectiveness of stretching alone for spasticity reduction 3, 4
• More active strategies should be prioritized over passive interventions 4:
  • Functional electrical stimulation (FES)
  • Neuromuscular electrical stimulation (NMES)
  • Transcutaneous electrical nerve stimulation (TENS)
  • Resistance training
  • Lower extremity ergometer training

Pharmacological Management

1. Tizanidine:

   • First-line oral medication for post-stroke spasticity 1, 5
   • Start with low dose (2mg once daily) and gradually titrate up 1
   • Particularly effective for chronic stroke patients with spasticity and pain without loss of motor strength 2
   • Short-acting and should be reserved for daily activities when relief of spasticity is most important 5

2. Baclofen:

   • Alternative first-line oral medication 2, 1
   • GABA-B receptor agonist effective for spasticity
   • Caution: May cause significant sedation and have less impact on spasticity in stroke compared to other conditions 2
   • Avoid abrupt discontinuation to prevent withdrawal complications 1

3. Dantrolene:

   • Consider when cognitive side effects must be minimized 2, 1
   • Start at low doses (25mg daily) and titrate slowly 1
   • Limited trial data in stroke patients 2
   • Note: Early initiation before onset of disabling spasticity showed no change in clinical tone or functional outcome 2

4. Diazepam:

   • Relatively contraindicated in stroke patients, especially during recovery period 2
   • Associated with decreased cognitive performance 1

Second-Line Interventions

Focal Spasticity Management

• Botulinum toxin type A injections are first-line for focal or multifocal spasticity 6, 7
  • Dosage: 100-300 IU based on affected muscles 1
  • Particularly useful for painful spasticity that impairs function or positioning 1
  • Should be combined with positioning measures and physical therapy 6

Orthotic Management

• Splinting, serial casting for developing contractures 2, 1
• Knee-ankle-foot orthoses can prevent knee buckling during ambulation 1

Advanced Interventions for Refractory Spasticity

Intrathecal Baclofen

• Indicated for severe spasticity unresponsive to oral medications 2, 1
• Demonstrated to reduce spasticity in chronic stroke patients (>6 months post-stroke) 2
• Requires surgical implantation of pump system

Surgical Options

• Consider for contractures that interfere with function 2, 1
• Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesions) lack clinical trial evidence and carry significant risks 2

Monitoring and Management Considerations

• Focus treatment on improving pain, skin hygiene, and function rather than just reducing muscle tone 1
• Regularly assess skin integrity as spasticity can contribute to pressure ulcer development 1
• Identify and treat factors that can worsen spasticity (skin pressure sores, fecal impaction, urinary tract infections) 1
• Use standardized scales to assess improvement in spasticity 1

Common Pitfalls to Avoid

• Focusing solely on reducing muscle tone without addressing functional improvement
• Neglecting to identify and treat factors that can worsen spasticity
• Using diazepam during stroke recovery period due to negative effects on recovery 2, 1
• Abrupt discontinuation of baclofen (can cause serious withdrawal) 1
• Delaying diagnosis and treatment, which can lead to harmful consequences like contractures 6
• Failing to distinguish spasticity from other types of hypertonia (e.g., dystonia) 6

Despite the variety of available treatments, they are limited by dose-dependent adverse effects, high cost, and sometimes limited therapeutic efficacy 8. The most recent high-quality evidence (GRADE A) supports a multimodal approach including stretching exercises, electrical stimulation techniques, botulinum toxin A injections, and intrathecal baclofen for improving functional recovery and quality of life in post-stroke spasticity 7.