What are the treatment options for managing spasticity?

Management of Spasticity

Spasticity should be treated using a stepwise approach starting with physical modalities (positioning, range of motion exercises, stretching), followed by botulinum toxin injections for focal spasticity, oral antispasticity medications for generalized spasticity, and finally intrathecal baclofen or surgical interventions for refractory cases. 1

Initial Assessment and Physical Interventions

Start with non-pharmacological interventions as the foundation of all spasticity management:

• Implement antispastic positioning, range of motion exercises, stretching, splinting, and serial casting several times daily 1
• These physical modalities should be performed multiple times per day in persons with spasticity to prevent contractures 1
• Physical modalities such as neuromuscular electrical stimulation (NMES) or vibration applied to spastic muscles may temporarily improve spasticity as an adjunct to rehabilitation therapy 1
• Avoid splints and taping for prevention of wrist and finger spasticity after stroke, as they are not recommended 1

Pharmacological Treatment Algorithm

For Focal Spasticity (Localized to Specific Muscle Groups):

Botulinum toxin is the first-line pharmacological treatment for focal spasticity:

• Targeted injection of botulinum toxin into localized upper limb muscles is recommended (Class I, Level A evidence) to reduce spasticity, improve passive or active range of motion, and improve dressing, hygiene, and limb positioning 1
• Targeted injection of botulinum toxin into lower limb muscles is recommended (Class I, Level A evidence) to reduce spasticity that interferes with gait function 1
• Botulinum toxin (onaBoNT-A) is superior to tizanidine for patients with upper limb spasticity 2
• Consider phenol or alcohol nerve blocks as alternatives for selected patients with disabling or painful focal spasticity 1

For Generalized Spasticity (Multiple Muscle Groups):

Use oral antispasticity agents when spasticity causes pain, poor skin hygiene, or decreased function:

• Consider tizanidine, dantrolene, or oral baclofen for generalized spasticity 1
• Tizanidine is specifically indicated for chronic stroke patients and has shown efficacy in improving spasticity and pain without loss of motor strength 1
• Baclofen is a GABAB agonist; start at 5 mg up to three times daily, with gradual titration (older adults rarely tolerate >30-40 mg/day) 2
• Dantrolene acts directly on skeletal muscle but carries a black box warning for potentially fatal hepatotoxicity (0.1-0.2% of patients on long-term treatment) 2
• Oral antispasticity agents can be useful for generalized spastic dystonia but may result in dose-limiting sedation or other side effects (Class IIa, Level A evidence) 1

Critical Medication Contraindication:

Avoid diazepam and other benzodiazepines during the stroke recovery period due to deleterious effects on recovery and sedation side effects 1

Advanced Interventions for Refractory Spasticity

Intrathecal Baclofen:

For severe spasticity unresponsive to oral medications and focal treatments:

• Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions (Class IIb, Level A evidence) 1
• Consider intrathecal baclofen for chronic stroke patients with spasticity causing pain, poor skin hygiene, or decreased function 1
• Can be considered as early as 3-6 months after stroke for patients refractory to other treatments 1
• Intrathecal baclofen can reduce the need for oral antispasticity medications 2

Neurosurgical Options:

For severe, refractory cases when other interventions have failed:

• Consider neurosurgical procedures such as selective dorsal rhizotomy or dorsal root entry zone lesion for spasticity resulting in pain, poor skin hygiene, or decreased function 1
• Surgical correction may be necessary for contractures that interfere with function 1

Important Clinical Considerations

Treatment indications - Only treat spasticity when it causes harm:

• Spasticity should be treated if it causes pain, affects mobility, ADLs, or sleep 1
• Spasticity does not always require treatment and can sometimes assist in rehabilitation (e.g., enabling standing when limb weakness is present) 3
• Address indirect factors that may exacerbate spasticity: urinary tract infections, fecal impaction, pressure sores 1

Monitoring and safety:

• Monitor patients on baclofen for muscle weakness, urinary function changes, cognitive effects, and sedation 2
• Never abruptly discontinue baclofen - can cause severe CNS irritability and withdrawal symptoms 2
• Early treatment is key to preventing contractures, which can render the affected limb functionless 1

Realistic expectations:

• Most controlled trials show that oral antispasticity medications may reduce spasticity and pain but typically do not produce significant functional gains 1
• Tizanidine is a short-acting drug and should be reserved for daily activities and times when relief of spasticity is most important 4