Karen K. Bloom, MD, FACP
Rehab Associates, Louisville, Kentucky

Spasticity may have some benefits. It prevents muscle atrophy or decrease in muscle size. That is why people with upper motor lesions usually maintain their muscle bulk. Spasticity may help to control swelling in feet and may also lock weak muscles into place to make transfers or weight bearing easier.

However, spasticity may also contribute to pressure sores, be the cause of contractures, prevent proper positioning, and mask recovery of muscle function. As stated above, some people need a little bit of spasticity to perform certain functions like transfers yet too much muscle tone may prevent the ability to perform them. In this situation, treatment for spasticity is needed though it may be difficult to decrease the tone yet leave enough "useful" tone so that a person can successfully transfer.

Spasticity from spinal cord injury is actually different than spasticity found in persons who have suffered stroke, brain injury, or cerebral palsy. In spinal cord injury, it is frequently described as spasms. Flexor spasms occur more frequently than extensor spasms. Because the cause of the increase in muscle tone is different in spinal cord injury, it may be treated with some medications not used in spasticity of other origins.

Diazepam (Valium) is an old, effective medication. It works well but may be very sedating. People can develop a tolerance to diazepam and it is highly addictive. It is often used in conjunction with other medicines in order to keep the dose at a minimum. Many physicians prefer not to prescribe diazepam because of its negative attributes.

Dantrolene (Dantrium) is another older line of treatment for spasticity1. It does not cross the blood brain barrier and therefore does not cause sedation. However, it is metabolized by the liver and may cause liver toxicity, especially in smokers. It may cause muscle weakness and should be used with great caution in persons with respiratory insufficiency (spinal cord levels C4-C7). If used, liver function tests should be checked at regular intervals.

Baclofen (Lioresal) is commonly used for spasms in spinal cord injury.2 It may cause sedation or nausea as the dose is increased. However, if the dose is titrated up slowly it is usually well tolerated. It comes in several forms. It may be taken in pill form or it may be pumped directly into the spinal fluid (intrathecal).3 The advantage of intrathecal baclofen is that it can be given in minute doses thereby minimizing the side effects. However, in order for it to be pumped into the spinal fluid the person must undergo a test dose of baclofen through a spinal tap. If successful, then a pump the size of a hockey puck is implanted under the skin along with a catheter that runs into the spinal canal. This minimizes the medications a person has to take to control their spasticity.

Tizanidine (Zanaflex) is a medicine that was made for people with spasticity from spinal cord injury.4 It is very effective. It may cause a drop in blood pressure or drowsiness. Thus, it must be titrated up slowly. Because of its sedating properties, people will often use it to help them sleep. People develop a tolerance to the sedation.

Gabapentin (Neurontin) is a medicine used to prevent seizures. It has been used off label for the treatment of spasticity. It may also be sedating and therefore the dose should be gradually increased. Gabapentin is also useful for the treatment of pain.

Because the side effects of all of these medicines may be problematic, combinations of medicines may be used to try to keep down the incidence and severity of side effects.

Rarely, nerve blocks or motor point blocks may be used in the treatment of spasticity. Phenol, an alcohol derivative may be injected into muscle or around nerves by a specially trained physician.5 Botulinum toxin may also be injected into specific muscle groups by physicians who are specifically taught how to administer it.6 These, injectable medicines work by weakening muscle groups that may be aggravating the spasticity.

The safest and most basic way to treat spasticity is to stretch weak or paralyzed muscles in the morning upon awakening. This is when muscles are the tightest. Splinting is also important for both treating spasticity as well as preventing muscle contractures. Spasticity is made worse by irritation to the body such as bladder infections, ingrown toenails, fractures, dislocations, pressure sores, blood clots, and many other causes.

The most important thing to remember in the management of spasticity is to stretch at least once a day. Use splints as recommended by the physician or therapist. Keep healthy! Inspect skin on a regular basis, perform pressure reliefs, drink plenty of fluids, and eat a well balanced diet.

1. Mayer N, Mecomer S, Hermanh R. Treatment of spasticity with dantrolene sodium. American Journal of Physical Medicine. 1973;52:18-29.

2. Davidoff R. Antispasticity drugs: mechanisms of action. Annals of Neurology. 1985;17:107-116.

3. Penn R. Intrathecal baclofen for spasticity of spinal origin: seven years of experience. Journal of Neurosurgery. 1992;77:236-240.

4. Young R. Role of tizanidine in the treatment of spasticity. Neurology. 1994;44:S1-80.

5. Mooney V, Frykman G, McLamb J. Current status of intraneural phenol injections. Clinical Orthopedics and Related Research. 1969;3:122-131.

6. Snow B, Tsui J, Bhatt M, Varelas M, Hashimoto S, Caine D. Treatment of spasticity with botulinum toxin: a double-blind study. Annals of Neurology. 1990;28:512-515.