What are the treatment options for spasticity?

Treatment of Spasticity

Baclofen is the first-line pharmacological agent for generalized spasticity, starting at 5 mg three times daily and titrating gradually, while botulinum toxin injections are the preferred first-line treatment for focal spasticity. 1, 2

Treatment Algorithm

Initial Assessment and Non-Pharmacological Management

• Immediately initiate range-of-motion exercises, antispastic positioning, and proper body alignment to prevent contracture progression and reduce reflex hyperexcitability 1
• Implement stretching programs and splinting to maintain joint mobility 1
• Physical therapy must always accompany any pharmacological intervention 3

Pharmacological Management Based on Spasticity Pattern

For Focal Spasticity:

• Botulinum toxin injections targeting specific muscles are the first-line pharmacological treatment 2
• Botulinum toxin (onaBoNT-A) is superior to oral medications like tizanidine for upper limb spasticity 2
• Particularly effective for hemiplegic shoulder pain related to spasticity when injected into subscapularis and pectoralis muscles 4

For Generalized Spasticity:

• Baclofen (GABA-B agonist) is the preferred first-line agent 1, 2

  • Start at 5 mg three times daily 1, 2
  • Titrate gradually; older adults rarely tolerate doses above 30-40 mg daily 2
  • Particularly effective for flexor spasms and concomitant pain in spinal cord injury patients 1
  • Critical warning: Never allow abrupt discontinuation—can cause life-threatening withdrawal syndrome 2, 5

• Tizanidine (alpha-2 adrenergic agonist) as alternative 2

  • Start at 2 mg up to three times daily 2
  • Acts through central mechanisms to reduce muscle tone 2

• Avoid benzodiazepines (diazepam) during recovery phases—they may negatively impact neurological recovery despite GABA-A agonist activity 1, 2

• Dantrolene (direct skeletal muscle relaxant) 2

  • Reserved for when direct action on skeletal muscle is desired 2
  • Black box warning: potentially fatal hepatotoxicity in 0.1-0.2% of long-term users 2

Monitoring Requirements for Baclofen Therapy

When initiating baclofen, closely monitor for:

• Muscle weakness that could impair residual function 1
• Urinary function changes 1
• Cognitive effects and sedation 1, 2

Severe or Refractory Spasticity

• Intrathecal baclofen via programmable pump delivers medication directly to the spinal cord for severe, refractory cases 1, 2, 6
• This is appropriate when oral medications fail to provide adequate relief 2
• Urgent refill management is critical—pump running empty creates life-threatening withdrawal risk evolving over 1-3 days 5
• High-dose benzodiazepine IV infusion or oral baclofen may be lifesaving before intrathecal therapy can be resumed 5

Common Pitfalls to Avoid

Abrupt Baclofen Discontinuation:

• This is the most dangerous error—can cause catastrophic withdrawal syndrome with CNS irritability and potentially fatal consequences 2, 5
• Always taper gradually if discontinuation is necessary 2

Unrealistic Treatment Expectations:

• Antispastic drugs treat spasticity but do not treat contractures or restore function to hemiplegic limbs unless spasticity itself impedes function 7
• Paresis, fatigability, and lack of dexterity—not spasticity—account for most functional disability in upper motor neuron lesions 8

Treating Spasticity When Not Harmful:

• Only treat spasticity when it causes harm and interferes with active or passive functioning 7
• Document intended outcomes in writing and agree upon them with the patient before initiating treatment 7

Using Benzodiazepines During Recovery:

• Despite their antispastic properties, benzodiazepines should be avoided during stroke or injury recovery phases due to negative effects on neurological recovery 1, 2