What are the treatment options for managing hemi paretic (half body paralysis) spasms?

Treatment Options for Hemiparetic Spasms

Botulinum toxin injections are the first-line treatment for hemiparetic spasms related to spasticity, particularly when targeting specific muscle groups like the subscapularis and pectoralis muscles in the upper extremity. 1

Initial Assessment and Non-Pharmacological Approaches

• Assessment of hemiparetic spasms should include evaluation of tone, strength, changes in soft tissue length, joint alignment, pain levels, and orthopedic changes 1
• Active, active-assisted, or passive range of motion exercises should be implemented early to prevent contractures and complex regional pain syndrome (CRPS) 1
• Positioning, stretching, and mobilization techniques should focus on increasing external rotation and abduction for upper extremity spasticity 1
• Functional dynamic orthoses may facilitate repetitive task-specific training for affected limbs 1

Pharmacological Management

Oral Medications

• If no contraindications exist, analgesics such as acetaminophen or ibuprofen can be used for pain relief associated with spasticity 1
• Oral antispasmodic medications can be considered in this order:
  1. Tizanidine (starting at 300 mg at bedtime, up to 2400 mg daily in divided doses) - particularly effective for chronic stroke patients 1, 2
  2. Dantrolene for spasticity resulting in pain, poor skin hygiene, or decreased function 1
  3. Oral baclofen (though efficacy in stroke has not been established according to FDA labeling) 1, 3
• Avoid benzodiazepines during stroke recovery due to potential negative effects on recovery and sedation side effects 1

Injectable Treatments

• Botulinum toxin injections into specific muscles (such as subscapularis and pectoralis) are effective for treating spasticity-related pain and improving range of motion 1
• Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region in the hemiplegic shoulder 1

Advanced Interventions

• For severe, intractable spasticity unresponsive to other treatments, intrathecal baclofen (ITB) may be considered, but with caution 4
• ITB must be used carefully in stroke patients as it may weaken the paretic side and suppress antigravity patterns used for ambulation 5

Management of Associated Conditions

Hemiplegic Shoulder Pain

• Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may be considered as adjuncts to upper extremity therapy 1

Complex Regional Pain Syndrome (CRPS)

• For CRPS associated with hemiparesis, an early course of oral corticosteroids (30-50 mg daily for 3-5 days, with tapering doses over 1-2 weeks) can reduce swelling and pain 1
• Diagnosis should be based on clinical findings including pain and tenderness of joints, edema, trophic skin changes, hyperesthesia, and limited range of motion 1

Rehabilitation Approaches

• Balance training should be offered to patients with balance disorders post-stroke 1
• Effective interventions include trunk training, task-oriented intervention, force platform biofeedback, and structured progressive exercise programs 1
• For lower limb spasticity, transcutaneous electrical nerve stimulation (TENS) may be as effective as or more effective than oral baclofen with fewer side effects 6

Important Considerations and Pitfalls

• Functional assessment is critical before treatment, as reducing spasticity may sometimes worsen function if the patient relies on spasticity for stability or movement patterns 5
• Spasticity management should aim to decrease tone without reducing muscle strength needed for functional activities 1
• Regular reassessment is essential to determine if changes to treatment are required or if equipment can be discontinued as the patient improves 1
• Adaptive devices should be evaluated on an individual basis and may be necessary for safety and function 1