Treatment for Post-Stroke Spasticity
The optimal treatment for post-stroke spasticity follows a stepwise approach, beginning with physical therapy and oral medications like tizanidine or baclofen, progressing to botulinum toxin injections for focal spasticity, and considering intrathecal baclofen only for severe cases unresponsive to other treatments. 1
First-Line Interventions
Non-Pharmacological Approaches
- Positioning, passive stretching, and range-of-motion exercises several times daily
- Functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), and transcutaneous electrical nerve stimulation (TENS)
- Resistance training and lower extremity ergometer training
- Orthotic management (e.g., knee-ankle-foot orthoses) to prevent knee buckling during ambulation
- Gentle stretching and mobilization to prevent contractures 1
First-Line Oral Medications
Tizanidine:
- First-line oral medication, particularly effective for chronic stroke patients with spasticity and pain
- Start with low dose (2mg once daily) and gradually titrate up
- High evidence supporting effectiveness 1
Baclofen:
- Alternative first-line oral medication (GABA-B receptor agonist)
- May cause significant sedation
- Less impact on spasticity in stroke compared to other conditions
- Avoid abrupt discontinuation to prevent withdrawal complications
- Moderate evidence supporting effectiveness 1
- Note: A 2018 study showed low responder rate to oral baclofen, with only 3 out of 29 participants showing significant improvement 2
Dantrolene:
- Consider when cognitive side effects must be minimized
- Start at low doses (25mg daily) and titrate slowly
- Limited trial data in stroke patients 1
Second-Line Interventions
Botulinum Toxin Injections
- First-line for focal or multifocal spasticity
- Recommended dosage: 100-300 IU based on affected muscles
- Should be combined with positioning measures and physical therapy
- High evidence supporting effectiveness 1
Advanced Interventions
Intrathecal Baclofen (ITB)
- Indicated for severe spasticity unresponsive to oral medications
- Requires surgical implantation of a pump system
- Effective for reducing spasticity in chronic stroke patients (>6 months post-stroke) 1
- Significantly improves pain and quality of life in post-stroke spasticity 3
- Important considerations:
- May cause functional deterioration in patients who rely on spasticity for antigravity patterns during ambulation 4
- Despite benefits, fewer than 1% of stroke patients with severe disabling spasticity receive ITB therapy 5
- Most beneficial for patients with severe multilimb spasticity not responding to other treatments 6
Surgical Interventions
- Splinting and serial casting for developing contractures
- Surgical correction may be considered for contractures that interfere with function
- Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesions) lack clinical trial evidence and carry significant risks 1
Management of Complications
- Focus treatment on improving pain, skin hygiene, and function rather than just reducing muscle tone
- Regularly assess skin integrity as spasticity can contribute to pressure ulcer development
- Identify and treat factors that can worsen spasticity:
- Skin pressure sores
- Fecal impaction
- Urinary tract infections
- Bladder stones 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 (relatively contraindicated due to negative effects on recovery)
- Abrupt discontinuation of baclofen (can cause serious withdrawal)
- Delaying diagnosis and treatment (can lead to harmful consequences like contractures)
- Failing to distinguish spasticity from other types of hypertonia (e.g., dystonia) 1
- Overlooking the potential functional deterioration with ITB in patients who rely on spasticity patterns for ambulation 4