Initial Management of Spinal Cord-Related Flexion Contracture and Spasticity
For spinal cord injury patients with flexion contractures and spasticity, begin immediately with range-of-motion exercises, positioning, and stretching, then add oral baclofen (starting at 5 mg three times daily) as first-line pharmacological therapy, specifically targeting flexor spasms and muscular rigidity. 1, 2, 3, 4
Non-Pharmacological Interventions (First-Line)
The initial approach must prioritize physical modalities before medications:
- Range-of-motion exercises should be initiated immediately to prevent contracture progression 1, 5
- Antispastic positioning and proper body alignment reduce reflex hyperexcitability 1, 5
- Stretching programs and splinting help maintain joint mobility and prevent fixed contractures 1, 5
- Serial casting may be necessary for established contractures 5
These interventions address the underlying pathophysiology—spasticity represents a hyper-excitable state of spinal reflex arcs below the injury level, affecting skeletal motor systems 6
Pharmacological Management Algorithm
First-Line Oral Medication: Baclofen
Baclofen is FDA-approved specifically for spasticity from spinal cord injuries and is particularly effective for flexor spasms and concomitant pain 3, 4:
- Starting dose: 5 mg three times daily 2
- Titration: Increase gradually; older patients rarely tolerate >30-40 mg/day 2
- Mechanism: GABA-B agonist that reduces spinal reflex hyperexcitability 2, 7
- Target symptoms: Flexor spasms, muscular rigidity, and pain associated with spasticity 3, 4, 7
Alternative Oral Agents
If baclofen is not tolerated or contraindicated:
- Tizanidine: Start 2 mg three times daily; centrally acting alpha-2 adrenergic agonist 2, 8
- Dantrolene: Acts directly on skeletal muscle; carries black box warning for hepatotoxicity (0.1-0.2% risk) 2
Avoid benzodiazepines (diazepam) during recovery phases as they may negatively impact neurological recovery 1, 2, 5
Critical Monitoring Requirements
When initiating baclofen therapy, monitor closely for:
- Muscle weakness that could impair residual function 2
- Urinary function changes 2
- Cognitive effects and sedation 2
- Never abruptly discontinue—can cause severe CNS withdrawal symptoms 2
When to Escalate Treatment
For Focal Spasticity
If specific muscle groups remain problematic despite oral medications:
- Botulinum toxin injections target specific muscles causing contracture 1, 5
- Phenol nerve blocks for localized muscle groups 1
For Severe, Refractory Spasticity
When oral medications fail at maximum tolerated doses:
- Intrathecal baclofen via programmable pump delivers drug directly to spinal cord 1, 2, 9, 10
- Doses range 21-500 mcg/24 hours (mean 160 mcg/24 hours) 9
- Reduces muscle tone from Ashworth score 4.0 to 1.2 and maintains long-term control 10
- Requires careful dose titration to avoid overdose complications 9
Surgical Options (Last Resort)
Only consider after all conservative measures fail:
- Selective longitudinal myelotomy is preferred over destructive procedures 6
- Tendon lengthening/release for fixed contractures after spasticity control 6, 11
- Avoid destructive procedures (rhizotomies, cordectomies) as they are too invasive 6
Critical Pitfall: Identifying Underlying Causes
Excessive spasticity should be treated as a pain equivalent in spinal cord injury patients 6:
- Search for triggering conditions: urinary tract infections, fecal impaction, pressure ulcers, calculi 1, 6
- These normally painful conditions trigger hyper-sensitive reflexes, worsening spasticity 6
- Treating the underlying condition often reduces spasticity more effectively than increasing medications 6