Is baclofen (GABA receptor agonist) recommended for managing contracture with spasticity in patients with neurological conditions such as cerebral palsy, spinal cord injury, or stroke?

Baclofen for Contracture with Spasticity

Baclofen is recommended for managing spasticity but NOT for established contractures; it should be used as part of a treatment algorithm that prioritizes non-pharmacological interventions first, with the goal of preventing contractures rather than treating them once formed. 1, 2

Critical Distinction: Spasticity vs. Contracture

• Spasticity is a velocity-dependent hyperactivity of tonic stretch reflexes that is treatable with baclofen 2
• Contractures are fixed structural changes in muscle and connective tissue that do not respond to antispasticity medications 1
• Once contractures develop, surgical correction or serial casting becomes necessary rather than pharmacological management 1

FDA-Approved Indications and Limitations

• Baclofen is FDA-approved for spasticity from multiple sclerosis and spinal cord diseases, particularly for relief of flexor spasms, pain, clonus, and muscular rigidity 3
• The FDA label explicitly states that efficacy in stroke, cerebral palsy, and Parkinson's disease has not been established and is therefore not recommended for these conditions 3
• Patients must have reversible spasticity for baclofen to aid in restoring residual function 3

Treatment Algorithm for Spasticity Management

First-Line Non-Pharmacological Approaches

• Antispastic positioning, range of motion exercises, stretching, splinting, and serial casting should be initiated before any pharmacological intervention 1, 2
• These interventions have moderate-to-strong evidence for preventing contracture development 2

Second-Line Pharmacological Options

For Focal Spasticity:

• Botulinum toxin is preferred over baclofen for focal spasticity (e.g., hand contractures post-stroke) as it is more effective and better tolerated 1, 2
• A small RCT found botulinum toxin superior to oral baclofen specifically for ankle spasticity 1

For Generalized Spasticity:

• Oral baclofen (30-80 mg/day divided into 3-4 doses) is recommended when spasticity causes pain, poor skin hygiene, or decreased function 1, 2
• Start at low doses (5-10 mg/day) and titrate slowly to minimize side effects including sedation, dizziness, and weakness 1
• Alternative oral agents include tizanidine (which causes less weakness) and dantrolene 1

Third-Line: Intrathecal Baclofen

• Reserved for severe spasticity unresponsive to maximum oral doses, with >80% of patients showing improvement in muscle tone and >65% improvement in spasms 1, 4, 5
• Requires only 1/100th the oral dose for equivalent effect 4
• Allows programmable dosing (e.g., lower during day for ambulation, higher at night for sleep) 4

Critical Warnings and Contraindications

Functional Deterioration Risk

• In stroke patients with hemiparesis, baclofen may eliminate the antigravity patterns needed for ambulation, causing loss of residual walking ability 6
• Six of eight stroke patients in one study experienced functional deterioration when ITB weakened their paretic side 6
• This represents a major limitation when patients rely on spasticity-driven extensor tone for mobility 6

Withdrawal Syndrome

• Abrupt cessation causes life-threatening withdrawal with high fever, altered mental status, rebound spasticity, seizures, hallucinations, and potential death 1
• Never abruptly discontinue baclofen; taper slowly over weeks 1
• Even high-dose oral baclofen may not prevent withdrawal in patients on intrathecal therapy 1

Other Precautions

• Avoid in hepatic dysfunction, severe renal impairment (start at 5 mg/day if used), and elderly patients due to increased CNS toxicity 1
• Can cause respiratory depression in overdose 1
• Avoid benzodiazepines during stroke recovery as they have deleterious effects on neurological recovery 1, 2

Special Population Considerations

Renal Impairment

• Start at 5 mg/day with mandatory dose reduction due to renal clearance 1
• Titrate gradually every 2-5 weeks with close monitoring for toxicity 1

Cerebral Palsy

• Intrathecal baclofen reduces upper and lower extremity spasticity and improves activities of daily living in severe cases 7
• Catheter complications occur in ~20% and infection requiring pump removal in ~5% 7
• No effect on athetosis at doses used for spasticity 7

When Baclofen Should NOT Be Used

• Established fixed contractures (requires surgical intervention) 1
• Primary goal is pain management without spasticity (use gabapentinoids instead) 1
• Stroke patients relying on extensor tone for ambulation 6
• Skeletal muscle spasm from rheumatic disorders (not FDA-approved) 3