What are the treatment options for a patient with spasticity?

Treatment of Spasticity

Begin with non-pharmacological interventions (antispastic positioning, range of motion exercises, stretching, splinting, serial casting), then progress to botulinum toxin for focal spasticity or oral medications (baclofen, tizanidine, dantrolene) for generalized spasticity, reserving intrathecal baclofen for severe refractory cases. 1, 2, 3

First-Line Non-Pharmacological Approaches

All patients with spasticity should receive physical modalities regardless of whether medications are used. 3

• Implement range-of-motion exercises multiple times daily to prevent contracture progression 3
• Apply antispastic positioning and proper body alignment to reduce reflex hyperexcitability 3
• Use stretching programs and splinting to maintain joint mobility 1, 3
• Consider serial casting for established contractures that interfere with function 1, 3
• Surgical correction may be necessary for severe contractures restricting movement or causing pain 3

Pharmacological Treatment Algorithm

For Focal Spasticity (Affecting Specific Muscle Groups)

Botulinum toxin injections are the preferred first-line pharmacological intervention for focal spasticity. 1, 2, 3

• Botulinum toxin is more effective than oral baclofen for focal applications, particularly for hand spasticity post-stroke 1
• Use when spasticity causes pain, impairs function, reduces rehabilitation participation, or compromises positioning and skin care 1, 3
• Botulinum toxin is safe at recommended doses with limited side effects 4

For Generalized Spasticity (Multiple Muscle Groups)

Start with oral baclofen as the preferred first-line agent. 3

Baclofen Dosing

• Initiate at low doses (5-10 mg/day) and titrate slowly to minimize side effects 1, 3
• Target dose range is 30-80 mg/day divided into 3-4 doses 1, 2
• Baclofen is particularly effective for flexor spasms and concomitant pain in spinal cord-related spasticity 3

Alternative Oral Agents

• Tizanidine is FDA-approved and specifically recommended for chronic stroke patients 2, 3
• Dantrolene is another FDA-approved alternative for generalized spasticity 1, 2, 3

Critical Medication to Avoid

Do not use benzodiazepines (e.g., diazepam) during stroke recovery as they impair neurological recovery and cause excessive sedation 1, 2, 3

Advanced Interventions for Refractory Spasticity

Intrathecal Baclofen Therapy

Consider intrathecal baclofen for severe spasticity unresponsive to maximum tolerated doses of oral medications. 1, 3

• Intrathecal delivery requires only 10% of the systemic dose for equivalent effect 1, 3
• More than 80% of patients show improvement in muscle tone and >65% have improvement in spasms 3
• Indicated for spasticity causing pain, poor skin hygiene, or decreased function 1

Critical Safety Warning

Abrupt cessation of intrathecal baclofen can be catastrophic and potentially fatal. 1, 3

• Withdrawal syndrome evolves over 1-3 days with high fever, altered mental status, rebound spasticity, and muscle rigidity 1
• The best management is resuming intrathecal infusion immediately 1
• Even high-dose oral baclofen may not prevent acute withdrawal 1
• Maintain strict pump refill schedules to prevent withdrawal 1

Neurosurgical Options (Last Resort)

Selective dorsal rhizotomy or dorsal root entry zone lesion should only be considered for intractable spasticity when all other modalities fail. 1, 2, 3

Treatment Selection Based on Clinical Presentation

Decision Algorithm

1. All patients: Start non-pharmacological interventions immediately 1, 2, 3

2. Focal spasticity (one or two muscle groups): Botulinum toxin injections 1, 3

3. Generalized spasticity: Oral baclofen (first choice), tizanidine, or dantrolene 2, 3

4. Refractory to oral medications at maximum tolerated doses: Intrathecal baclofen 1, 3

5. Failed all medical interventions: Neurosurgical procedures 1, 2, 3

Common Pitfalls and Caveats

• Baclofen can cause respiratory depression and should be used with extreme caution in patients with compromised respiratory function 1
• Baclofen may worsen obstructive sleep apnea by promoting upper airway collapse 1
• Baclofen may be contraindicated in significant hepatic dysfunction due to increased CNS effects 1
• Do not neglect physical modalities even when medications are effective, as they remain essential throughout treatment 3
• Ensure realistic expectations for both patients and caregivers about functional outcomes 2, 4