From the FDA Drug Label
Tizanidine’s capacity to reduce increased muscle tone associated with spasticity was demonstrated in two adequate and well controlled studies in patients with multiple sclerosis or spinal cord injury. The reduction in muscle tone was not associated with a reduction in muscle strength (a desirable outcome) but also did not lead to any consistent advantage of tizanidine treated patients on measures of activities of daily living. Baclofen tablets are useful for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity.
Refractory myofascial spasm is not directly addressed in the provided drug labels. However, both tizanidine 1 and baclofen 2 are used to treat spasticity.
- Tizanidine is used to reduce increased muscle tone associated with spasticity in patients with multiple sclerosis or spinal cord injury.
- Baclofen is used for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity. Since myofascial spasm is not the same as spasticity, and the labels do not directly address refractory myofascial spasm, the answer to the question about refractory myofascial spasm cannot be directly determined from the information provided.
From the Research
Refractory myofascial spasm should be managed with a multimodal approach, prioritizing trigger point injections with lidocaine or bupivacaine, as these have been shown to be effective in reducing pain and improving quality of life, as seen in studies such as 3 and 4.
Management Approach
The management of refractory myofascial spasm involves a combination of physical therapy, medications, and interventional procedures.
- First-line medications include muscle relaxants such as cyclobenzaprine (5-10mg three times daily), tizanidine (2-4mg three times daily), or baclofen (5-10mg three times daily).
- Anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) can help reduce inflammation.
- For severe cases, trigger point injections using lidocaine (1-2%) or bupivacaine (0.25-0.5%) with or without corticosteroids may provide relief.
Physical Therapy and Other Interventions
Physical therapy focusing on stretching, massage, and myofascial release techniques should be performed 2-3 times weekly for 4-6 weeks.
- Heat therapy, ultrasound, and electrical stimulation can complement these approaches.
- For truly refractory cases, botulinum toxin injections (50-100 units depending on the muscle group) may be considered, with effects lasting 3-4 months, as noted in studies such as 5 and 6.
Underlying Contributors
Addressing underlying contributors such as poor posture, ergonomic issues, and psychological stress is essential for long-term management.
- A comprehensive approach that includes lifestyle modifications and stress management techniques can help in reducing the frequency and severity of myofascial spasms.
- The most recent and highest quality study, 7, highlights the importance of trigger point injections in managing myofascial pain syndromes, further supporting the use of lidocaine or bupivacaine as a first-line treatment.