What is the treatment for upper limb spasticity secondary to stroke?

Treatment of Upper Limb Spasticity Secondary to Stroke

Botulinum toxin type A injections into affected upper limb muscles are the first-line pharmacological treatment for focal upper limb spasticity after stroke, with proven efficacy in reducing muscle tone, improving basic functional tasks (hand hygiene, dressing), and reducing pain. 1

Treatment Algorithm

First-Line Non-Pharmacological Approaches

• Initiate antispastic positioning, range of motion exercises, stretching, splinting, and serial casting as foundational interventions before or alongside pharmacological treatment 1
• These physical modalities should be performed several times daily in persons with spasticity 1
• Avoid using splints and taping for prevention of wrist and finger spasticity, as they are not recommended 1

First-Line Pharmacological Treatment: Botulinum Toxin

For focal upper limb spasticity (Class I, Level A recommendation):

• Botulinum toxin type A is recommended for targeted injection into localized upper limb muscles to reduce spasticity, improve passive or active range of motion, and improve dressing, hygiene, and limb positioning 1

Specific dosing for upper limb spasticity:

• Total doses of 500-1000 Units of abobotulinumtoxinA (Dysport) divided among affected muscles 2
• Common target muscles and doses 2:
  • Flexor carpi radialis/ulnaris: 100-200 Units per muscle
  • Flexor digitorum profundus/superficialis: 100-200 Units per muscle
  • Brachialis: 200-400 Units
  • Biceps brachii: 200-400 Units
  • Brachioradialis: 100-200 Units
  • Pronator teres: 100-200 Units

Clinical outcomes:

• Clinical improvement expected within 1-2 weeks after injection 2, 3
• Duration of benefit typically lasts 1-11 months, with most patients requiring retreatment at 12-16 weeks 2
• Significant improvements demonstrated in muscle tone, basic arm functional tasks (hand hygiene, facilitation of dressing), and pain reduction 4
• Important caveat: Botulinum toxin is unlikely to improve active upper limb function (reaching and grasping) in the majority of patients, but excels at improving basic tasks and reducing pain 4

Second-Line Pharmacological Treatment: Oral Antispasticity Agents

When generalized spasticity is present (Class IIa, Level A recommendation):

• Oral antispasticity agents (tizanidine, dantrolene, oral baclofen) can be useful for generalized spastic dystonia but may result in dose-limiting sedation or other side effects 1
• Tizanidine has demonstrated efficacy in chronic stroke patients with improvement in spasticity and pain without loss of motor strength 1
• Oral baclofen dosing: 30-80 mg/day divided into 3-4 doses, starting at 5-10 mg/day and titrating slowly 5
• Critical warning: Avoid diazepam or other benzodiazepines during the stroke recovery period due to deleterious effects on recovery 1

Third-Line Treatment: Intrathecal Baclofen

For severe refractory spasticity (Class IIb, Level A recommendation):

• Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions 1
• Consider as early as 3-6 months after stroke for patients refractory to other treatments 1
• Indicated for spasticity resulting in pain, poor skin hygiene, or decreased function 1, 5

Adjunctive Physical Modalities

• Neuromuscular electrical stimulation (NMES) or vibration applied to spastic muscles may be reasonable to improve spasticity temporarily as an adjunct to rehabilitation therapy (Class IIb, Level A) 1

Key Clinical Considerations

Injection technique optimization:

• Use of injection guiding techniques (electromyography, electrical stimulation, or ultrasound) is recommended to accurately target injection sites 2
• No more than 1 mL should generally be administered at any single injection site 2
• Maximum recommended total dose for upper and lower limb combined is 1500 Units 2

Common pitfalls to avoid:

• Do not expect botulinum toxin to restore active reaching and grasping function - it primarily benefits passive function, basic care tasks, and pain management 4
• Do not use benzodiazepines during stroke recovery - they impair neurological recovery 1
• Do not inject botulinum toxin more frequently than every 12 weeks 2

Cost-effectiveness considerations:

• Spasticity increases cost of care 4-fold, though the independent impact of spasticity treatment on overall costs remains unclear 1
• One study found botulinum toxin plus therapy was not cost-effective compared to therapy alone, though this must be weighed against quality of life improvements 1