What are the topical treatment options for patients with spasticity?

Topical Treatment Options for Spasticity

For spasticity management, botulinum toxin injections are the primary and most effective topical/local treatment option, particularly for focal spasticity, and should be prioritized over oral medications. 1, 2

First-Line Local Treatments

Botulinum Toxin (Primary Topical Agent)

• Botulinum toxin injections represent the gold standard for focal spasticity affecting specific muscle groups, with superior efficacy compared to oral agents like baclofen or tizanidine 1, 2

• Particularly effective for:

  • Upper limb spasticity (superior to tizanidine in this application) 2, 3
  • Hand contractures post-stroke (strongly recommended as first-line over baclofen) 1
  • Lower limb spasticity interfering with walking 1
  • Ankle spasticity (favored over oral baclofen in comparative trials) 1

• Should be combined with physical therapy for optimal functional outcomes 1, 2

Chemical Neurolysis (Alternative Local Agents)

When botulinum toxin is unavailable or for specific clinical scenarios, chemical neurolytic agents can be considered:

Phenol (Perineural Injection)

• Provides long-term chemical neurolysis through peripheral nerve destruction 4, 5
• More commonly used in adults via perineural injection 5
• May be preferred for larger proximal muscles 5
• Duration: Potentially longer than botulinum toxin 5

Ethanol (Intramuscular Injection)

• More commonly used in children via intramuscular injection 5
• Provides similar neurolytic effects to phenol 5

Local Anesthetics (Lidocaine)

• Fully reversible with short duration (minutes to hours) 5
• Useful for:
  • Therapeutic tests before long-acting agents 5
  • Diagnostic procedures to assess which muscles contribute to dysfunction 5
  • Preparation for casting 5
  • Analgesic before other intramuscular injections 5

Treatment Algorithm for Local/Topical Spasticity Management

Step 1: Non-Pharmacological Foundation (Always First)

• Antispastic positioning, range-of-motion exercises, stretching 4, 2
• Splinting or serial casting for contractures 4, 2
• Heat, cold, and electrical stimulation 4

Step 2: Focal Spasticity

• Primary choice: Botulinum toxin injections to affected muscle groups 1, 2
• Alternative: Phenol perineural blocks for larger proximal muscles 5
• Diagnostic aid: Lidocaine blocks to identify target muscles 5

Step 3: Combination Approach

• Neurolytic agents (phenol/ethanol) for larger proximal muscles combined with botulinum toxin for selective distal muscle injection 5

Critical Advantages and Disadvantages

Botulinum Toxin Advantages

• Highly selective motor function targeting 5
• Minimal chronic sensory side effects 5
• No tissue destruction 5
• Painless injection procedure 5

Neurolytic Agent Considerations

• Advantages: Earlier onset, potentially longer duration, lower cost, easier storage 5
• Disadvantages:
  • Pain during injection 5
  • Chronic dysesthesia and pain risk 5
  • Tissue destruction with sensory complications 5
  • Vascular complications possible 5
  • Less selective on motor function 5

Important Clinical Pitfalls

• Avoid benzodiazepines (like diazepam) during stroke recovery—they have deleterious effects on neurological recovery 1, 2
• Neurolytic agents require resuscitation equipment available during injection 5
• Always perform diagnostic lidocaine blocks before committing to long-acting neurolytic agents to confirm functional benefit 5
• For severely affected patients where comfort and hygiene are primary goals, neurolytic agents may be more appropriate than botulinum toxin 5

When Topical Treatments Are Insufficient

If focal treatments fail to control spasticity causing pain, poor hygiene, or functional decline:

• Consider intrathecal baclofen pump for severe refractory cases (requires only 10% of systemic dose with >80% improvement in muscle tone) 1, 2
• Oral agents (tizanidine preferred over baclofen for generalized spasticity) 2