What are the first-line pharmacological treatments for a patient with upper extremity contracture and a history of neurological disorders such as stroke or spinal cord injury leading to spasticity?

Pharmacological Treatment for Upper Extremity Contracture in Neurological Disorders

Botulinum toxin type A is the first-line pharmacological treatment for upper extremity contracture with spasticity following stroke or spinal cord injury, demonstrating superior efficacy over oral agents like baclofen for focal spasticity. 1, 2

First-Line Treatment: Botulinum Toxin Type A

For focal upper limb spasticity causing contracture, botulinum toxin type A should be offered as the primary pharmacological intervention. 1, 2

• AboBoNT-A, incoBoNT-A, and onaBoNT-A are all safe and effective options for reducing upper extremity spasticity and improving passive function (range of motion) 2
• Botulinum toxin reduces muscle tone, improves basic functional tasks, reduces pain, and facilitates better limb positioning and hygiene 1
• The American Academy of Neurology provides a Class I, Level A recommendation for botulinum toxin in targeted injection into localized upper limb muscles 1
• Meta-analysis demonstrates statistical superiority of botulinum toxin over placebo in reducing muscle tone (WMD= 0.95 [0.74 to 1.17]) in post-stroke upper limb spasticity 3

Essential Non-Pharmacological Foundation

Before or alongside pharmacological treatment, initiate antispastic positioning, range of motion exercises, stretching, splinting, and serial casting performed several times daily. 1, 4

• These physical interventions are foundational and should never be omitted 4
• All pharmacological interventions are adjunctive to physical management programs 5
• Important caveat: Splints and taping are NOT recommended for prevention of wrist and finger spasticity 1

Second-Line Oral Agents for Generalized Spasticity

When spasticity is generalized rather than focal, or when botulinum toxin is insufficient:

Oral Baclofen

• Dosing: Start at 5-10 mg/day, titrate slowly to 30-80 mg/day divided into 3-4 doses 4, 6
• FDA-approved specifically for spasticity from multiple sclerosis and spinal cord diseases 6
• Critical limitation: FDA label explicitly states efficacy in stroke has NOT been established 6
• Baclofen is primarily for generalized spasticity, not focal contractures 4

Tizanidine

• Recommended for chronic stroke patients with improvement in spasticity and pain without loss of motor strength 1
• Peak plasma concentration occurs 1 hour after dosing with approximately 2-hour half-life 7
• May cause dose-limiting sedation 1

Dantrolene

• Alternative oral agent for generalized spasticity 4, 8
• Can be considered when baclofen or tizanidine are ineffective or not tolerated 8

Critical Medications to AVOID

Do NOT use benzodiazepines (including diazepam) during stroke recovery—they have deleterious effects on neurological recovery. 1, 4

Third-Line: Intrathecal Baclofen

For severe spastic hypertonia unresponsive to oral medications and botulinum toxin, consider intrathecal baclofen as early as 3-6 months after stroke or spinal cord injury. 1, 4

• Indicated when maximum doses of oral baclofen fail 4, 8
• Studies show >80% of patients have improvement in muscle tone and >65% have improvement in spasms 4, 8
• Only 10% of the systemic dose is required via intrathecal route compared to oral administration 4
• Major risk: Abrupt cessation can cause life-threatening withdrawal syndrome with high fever, altered mental status, rebound spasticity, and muscle rigidity 4

Treatment Algorithm

1. Initiate physical interventions (positioning, ROM exercises, stretching, splinting, serial casting) 1, 4

2. For focal upper extremity contracture: Botulinum toxin type A injections into affected muscles 1, 2

3. For generalized spasticity: Oral baclofen (30-80 mg/day), tizanidine, or dantrolene 1, 4

4. For refractory severe spasticity: Intrathecal baclofen therapy 1, 4

5. Last resort: Neurosurgical procedures (selective dorsal rhizotomy, dorsal root entry zone lesion) 4

Adjunctive Therapies

• Neuromuscular electrical stimulation or vibration applied to spastic muscles may temporarily improve spasticity as an adjunct to rehabilitation 1
• Functional electrical stimulation and transcutaneous electrical nerve stimulation may improve upper-extremity motor outcomes 4, 8

Important Clinical Pitfalls

• Do not use baclofen as first-line for focal upper extremity contracture—it is less effective than botulinum toxin for focal spasticity 4, 8
• Baclofen may worsen obstructive sleep apnea by promoting upper airway collapse during sleep 4, 8
• Baclofen is NOT primarily indicated for pain management; gabapentinoids (pregabalin, gabapentin) are preferred for neuropathic pain 4, 8
• Elderly patients with renal insufficiency (creatinine clearance <25 mL/min) have >50% reduced tizanidine clearance, requiring dose adjustment 7
• Women taking oral contraceptives have 50% lower clearance of tizanidine 7