Post-Stroke Spasticity II: Management

 

The most important aspect of spasticity management is to stratify patients based on assessment tools such as Ashworth spasticity scale or its modified version, the frequency of spasms, and pain and reflex scales.[8] After knowing the extent of spasticity and patients priorities, then you can go ahead and think about your options:

Physical Therapy or Occupational Therapy: ROM activities, stretching, relaxation techniques, electrical muscle stimulators,…The efficacy of physical therapy depends on the severity of spasticity and not as efficacious as one would hope for, though it maintains the integrity of the joint at least to a certain degree and promotes joint mobility [7,8].

Acupuncture (or electroacupuncture): There are many randomized control trials that suggest acupuncture works for spasticity and competing numbers of trials suggesting the opposite. Lim and colleagues’ systematic review and meta analysis found that acupuncture could be beneficial in management of spasticity but further investigation is required [7,9].

Orthosis: If you ever go to a stroke unit or happen to drop in at a neuro rehab centre you notice that we are good at prescribing orthoses! from AFOs, knee braces, splints… are they effective? Well, anecdotally they are but very few evidence supports this claim! Although AFOs are not that helpful to improve gait and spasticity in ankle, but dynamic hand splints have shown some improvements if worn for a prolonged period of time on a daily basis [3,7,8,11].

 

Pharmachotherapy: Again depending on the severity of spasticity, comorbid conditions such as  hypotension and drug interactions different options are currently used. Some of these options are mainly used and studied in post stroke population and their applications in other neurological disorders might not be suitable.  Risk of falls due to dizziness, or dependance and withdrawal are barriers that physicians should think of.[3,8] There are 3 routes of administrations of these medications:

  1-Oral Medication:

Dantrolene sodium: Decreases hyperflexia, clonus, stiffness and cramps. But it might cause weakness, fatigue and drowsiness which might interfere with rehab. Many patients complaint of those side effects but it works for some patients[1,3,6].

Diazepam: Reduces muscle tone and frequency of spasms. but might lead to dependence, sedation and drowsiness. and generally it is not as effective in post stroke spasticity [2,3,4,6].

Oral Baclofen: Decreases painful spasms and improves range of motion. But can cause sedation, weakness and Hallucination due to withdrawal. this is a potent medication and can seriously put some people at risk of withdrawal [2,3,4,6,10].

Tizanidine Hydrochloride : Reduces muscle spasticity without altering muscle power which might be a good candidate during the rehab period. but again it might cause dizziness, fatigue and drowsiness [2,3,4,6].

Gabapentin: The efficacy of this drug has been mostly studied in spinal cord injury but it does reduce spasm and the pain associated with it. Many patients claim it helps them specifically with nocturnal spasms that keeps them awake at night [1,5].

2-Injections (Neurolytics):

Botulinum Toxin (Botox): Might be helpful for focal management of spasticity thought, it does seem to loose its efficacy in upper motor neuron syndromes such as stroke. It is mainly used in shorter muscles and upper extremities, but its use can be helpful in larger muscles too[6,7,8].

Phenol: It is used for proximal larger muscles and it reduces spasticity by a different mechanism than Botox, though its safety requires further studies[7,1].

3-Intrathecal:

Baclofen: This technique requires implantation of a pump underneath the skin of abdomen near the waistline, and the device can be programmed for various dosages and release timing. Due to battery limitation though the implantation needs to be repeated every 5-7 years[2,3].

 

Unfortunately, none of the above techniques and therapies have shown long term improvements and they come with several side effects and downfalls but currently those are the available options in clinical practice.

 

References:

[1] M. Gruenthal, M. Mueller, W. L. Olson, M. M. Priebe, A. M. Sherwood, and W. H. Olson, “Gabapentin for the treatment of spasticity in patients with spinal cord injury,” Spinal Cord, vol. 35, no. 10, pp. 686–689, Oct. 1997.
[2] “Intrathecal Baclofen Pump for Spasticity,” Ont Health Technol Assess Ser, vol. 5, no. 7, pp. 1–93, May 2005.
[3] S. M. Elbasiouny, D. Moroz, M. M. Bakr, and V. K. Mushahwar, “Management of Spasticity After Spinal Cord Injury: Current Techniques and Future Directions,” Neurorehabil Neural Repair, vol. 24, no. 1, pp. 23–33, Jan. 2010.
[4] S. Li and G. E. Francisco, “New insights into the pathophysiology of post-stroke spasticity,” Front Hum Neurosci, vol. 9, Apr. 2015.
[5] C. Trompetto et al., “Pathophysiology of Spasticity: Implications for Neurorehabilitation,” Biomed Res Int, vol. 2014, 2014.
[6] J. Cheung et al., “Patient-Identified Factors That Influence Spasticity in People with Stroke and Multiple Sclerosis Receiving Botulinum Toxin Injection Treatments,” Physiother Can, vol. 67, no. 2, pp. 157–166, 2015.
[7] J. E. Gallichio, “Pharmacologic Management of Spasticity Following Stroke,” Physical Therapy, vol. 84, no. 10, pp. 973–981, Oct. 2004.
[8] P. J. Gillard et al., “The negative impact of spasticity on the health-related quality of life of stroke survivors: a longitudinal cohort study,” Health Qual Life Outcomes, vol. 13, Sep. 2015.
[9] S. M. Lim et al., “Acupuncture for spasticity after stroke: a systematic review and meta-analysis of randomized controlled trials,” Evid Based Complement Alternat Med, vol. 2015, p. 870398, 2015.
[10] A. Pérez-Arredondo et al., “Baclofen in the Therapeutic of Sequele of Traumatic Brain Injury: Spasticity,” Clin Neuropharmacol, vol. 39, no. 6, pp. 311–319, Nov. 2016.
[11] C. Adrienne and C. Manigandan, “Inpatient occupational therapists hand-splinting practice for clients with stroke: A cross-sectional survey from Ireland,” J Neurosci Rural Pract, vol. 2, no. 2, pp. 141–149, 2011.

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