What medications are available to treat spasticity?

Two mainstays of treatment are baclofen (Lioresal®) and tizanidine (Zanaflex®, Tizaflex®). The major side effect of both drugs is sedation, which can be partially minimised by starting with a small dose and increasing slowly over time.

Second line therapeutic choices include benzodiazepines (such as Valium®), gabapentin (Neurontin®), and dantrolene (Dantrium®). Drowsiness is seen as a limiting factor for this group. Dantrolene has a more extensive side effect profile, including nausea, diarrhoea, incoordination, and possible liver toxicity. For people with severe spasticity resistant to oral medications, a few more aggressive approaches can be considered.

For focal spasticity, Botox® can be effective but must be targeted to specific muscle groups and repeat injections are required every 3-4 months. It can take 10-14 days to take full effect and needs to be combined with a stretching program and physiotherapy to be optimally effective.

Intrathecal Baclofen, administered through a baclofen pump, can produce dramatic improvement for more generalised spasticity in lower or upper limbs. The programmable pump is implanted in the abdomen and delivers a liquid form of baclofen directly to where it is needed—in the spinal canal. This route of delivery avoids the sedative effects of oral baclofen and allows small doses to be used. These pumps can be adjusted to deliver the appropriate amount of medication at the optimal time of day. Regular refilling of the pump, usually by the pain management team, is needed.

Candidates for the pump are initially assessed prior to implantation with a small test dose of baclofen. A positive response to the test dose gives confirmation that the implanted pump and catheter will be effective. The dose of baclofen is titrated up over the months after implantation to achieve an optimal effect. Potential complications may include catheter or pump failure that can lead to baclofen withdrawal syndrome due to the sudden decrease of the medication, and infection.

What can be done if neither Botox® nor the Baclofen pump work?

When spasticity is unresponsive to medications or physiotherapy, phenol nerve blocks are a possibility where phenol is injected into a nerve in large muscle groups, mainly in the thighs.

Surgical techniques may also offer improvement in symptoms and prevent contractures. These include tendon releases, dissection or cutting of peripheral nerves, and surgical severance of spinal cord roots.  

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