Is there a preference for certain muscle relaxants following a cerebrovascular accident (CVA) or stroke?

From the Guidelines

The most effective treatment for spasticity following stroke is targeted injection of botulinum toxin into localized muscles, which is recommended to reduce spasticity, improve passive or active range of motion, and improve dressing, hygiene, and limb positioning 1. When considering oral antispasticity agents, options such as baclofen, tizanidine, and dantrolene can be useful for generalized spastic dystonia, but may result in dose-limiting sedation or other side effects 1. Some key points to consider when treating spasticity following stroke include:

• Targeted injection of botulinum toxin into upper limb muscles is recommended to reduce spasticity and improve range of motion 1
• Oral antispasticity agents can be useful for generalized spastic dystonia, but may result in dose-limiting sedation or other side effects 1
• Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions 1
• Physical modalities such as NMES or vibration applied to spastic muscles may be reasonable to improve spasticity temporarily as an adjunct to rehabilitation therapy 1 It is essential to note that the choice of treatment depends on the individual's symptoms, medical history, and the type of spasticity present, and treatment should start with low doses and gradually increase to minimize side effects like sedation, weakness, and hypotension 1. Regular assessment of benefits versus side effects is essential for optimizing treatment, and physical therapy should accompany medication to maintain range of motion and function 1. The goal is to reduce painful muscle spasms and improve mobility without causing excessive weakness that might impair rehabilitation progress. In terms of specific medications, tizanidine should be used specifically for chronic stroke patients 1, and diazepam or other benzodiazepines should be avoided during the stroke recovery period due to possible deleterious effects on recovery 1. Overall, the treatment of spasticity following stroke should be individualized and based on the latest evidence-based guidelines, with a focus on improving mobility, reducing pain, and optimizing quality of life 1.

From the Research

Preference for Certain Muscle Relaxers Following Stroke

There are various muscle relaxers used to manage spasticity after a stroke, and the preference for a specific one may depend on several factors, including the severity of spasticity, patient response, and potential side effects.

• The efficacy and safety of oral baclofen in managing spasticity have been established, with studies suggesting it may be effective in many patients, regardless of the underlying disease or severity 2.
• However, oral baclofen can have adverse effects, such as muscle weakness, nausea, somnolence, and paraesthesia, affecting between 25% and 75% of patients, which may limit its usefulness 2.
• Intrathecal baclofen (ITB) has been shown to be an effective alternative, delivering the drug directly into the cerebrospinal fluid, thus bypassing the blood-brain barrier and minimizing drug-related side effects 2, 3.
• Botulinum toxin (BTX) injections have also been found to be an effective and well-tolerated focal treatment for reducing tonicity in patients with upper limb spasticity after stroke, with significant reductions in spasticity compared to oral tizanidine 4.
• A systematic review of contemporary pharmacologic treatments for upper limb spasticity after stroke found that BTX appeared to be an effective treatment, with 38 clinical trials reporting a significant reduction in spasticity 4.
• The pharmacological management of post-stroke muscle spasticity involves various drugs, including oral muscle relaxants, anticonvulsant drugs, ITB, cannabis extract, phenol, and alcohol, as well as botulinum toxin injections 5.
• A study on the effect of ITB on pain and quality of life in post-stroke spasticity found significant improvements in pain and quality of life in patients treated with ITB compared to conventional medical management 3.
• Another study on the effect of oral baclofen on spasticity post-stroke found that while the overall response rate was low, some participants responded to oral baclofen, highlighting the importance of individualized treatment approaches 6.