What is the recommended approach to using baclofen (GABA receptor agonist) to support physical therapy in patients with a history of Cerebrovascular Accident (CVA) and contracture to the hand?

Baclofen for Post-Stroke Hand Contracture Management

Botulinum toxin is recommended over baclofen for patients with focal spasticity affecting the hand following CVA, as it is more effective for focal spasticity that is painful, impairs function, reduces rehabilitation participation, or compromises positioning and skin care. 1, 2

First-Line Approaches for Post-Stroke Spasticity

• Begin with non-pharmacological interventions including antispastic positioning, range of motion exercises, stretching, splinting, and serial casting as the foundation of treatment 2, 3
• For focal spasticity in the hand, botulinum toxin injections are strongly recommended as the first-line pharmacological intervention 1, 3
• Physical therapy should be continued regardless of medication choice to maximize functional outcomes 3

Role of Baclofen in Post-Stroke Spasticity

• Oral baclofen is more appropriate for generalized spasticity rather than focal hand contractures following stroke 2, 3
• When using oral baclofen, start at low doses (5-10 mg/day) and titrate slowly to minimize side effects, with typical dosing ranges of 30-80 mg/day divided into 3-4 doses 2
• Baclofen's primary mechanism as a GABAB agonist targets spasticity, not primarily pain management 2

Important Considerations When Using Baclofen

• Significant adverse effects of baclofen include sedation, dizziness, mental confusion, and somnolence, with incidence ranging from 10% to 75% 4
• Adverse effects are dose-related and typically appear at doses >60 mg/day 4
• Avoid benzodiazepines (e.g., diazepam) during stroke recovery due to potential negative effects on recovery 2, 3

Alternative Approaches for Severe Spasticity

• For patients with severe spasticity unresponsive to oral medications, intrathecal baclofen may be considered 2, 4
• Intrathecal baclofen allows direct drug administration to the cerebrospinal fluid at concentrations less than one-hundredth of oral doses, minimizing central side effects 4
• Candidates for intrathecal baclofen must have no contraindications to intrathecal catheter insertion (e.g., anticoagulant therapy, coagulopathy, infection, spinal abnormalities) 4

Treatment Algorithm for Hand Contractures Post-CVA

1. First-line interventions:

   • Physical therapy with antispastic positioning, range of motion exercises, stretching, and splinting 2, 3
   • Botulinum toxin injections for focal hand spasticity 1, 3

2. Second-line interventions:

   • Oral baclofen starting at 5-10 mg/day, gradually titrating to effective dose (typically 30-80 mg/day divided into 3-4 doses) 2
   • Monitor for side effects and functional improvement 2, 4

3. For refractory cases:

   • Consider intrathecal baclofen for severe spasticity unresponsive to other interventions 2, 4
   • Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesion) as last resort options 2, 3

Monitoring and Evaluation

• Assess response within 24 hours of any dose change 5
• For adults with cerebral-origin spasticity (like post-stroke), daily dose increases should be 5-15% once every 24 hours 5
• Evaluate for both reduction in spasticity and improvement in functional outcomes 3, 5
• Regularly reassess the need for continued therapy and adjust dosing as needed 5