Treatment of Upper Limb Spasticity Secondary to Stroke

Introduction to Treatment Approaches

The American Heart Association recommends botulinum toxin type A injections into affected upper limb muscles as the first-line pharmacological treatment for focal upper limb spasticity after stroke, with proven efficacy in reducing muscle tone, improving basic functional tasks, and reducing pain 1

The American Stroke Association suggests initiating antispastic positioning, range of motion exercises, stretching, splinting, and serial casting as foundational interventions before or alongside pharmacological treatment, to be performed several times daily in persons with spasticity 1, 2
The American Stroke Association advises against using splints and taping for prevention of wrist and finger spasticity, as they are not recommended 1

The American Academy of Neurology recommends botulinum toxin type A for targeted injection into localized upper limb muscles to reduce spasticity, improve passive or active range of motion, and improve dressing, hygiene, and limb positioning, with a Class I, Level A recommendation 1
The American Stroke Association suggests oral antispasticity agents, such as tizanidine, dantrolene, and oral baclofen, can be useful for generalized spastic dystonia, but may result in dose-limiting sedation or other side effects, with a Class IIa, Level A recommendation 1
The American Heart Association recommends tizanidine for chronic stroke patients with improvement in spasticity and pain without loss of motor strength 2
The American Academy of Neurology advises against using diazepam or other benzodiazepines during the stroke recovery period due to deleterious effects on recovery 1, 2

The American Stroke Association suggests intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions, with a Class IIb, Level A recommendation 1
The American Academy of Neurology recommends considering intrathecal baclofen as early as 3-6 months after stroke for patients refractory to other treatments 1

The American Heart Association suggests neuromuscular electrical stimulation or vibration applied to spastic muscles may be reasonable to improve spasticity temporarily as an adjunct to rehabilitation therapy, with a Class IIb, Level A recommendation 1

The American Stroke Association notes that spasticity increases cost of care 4-fold, though the independent impact of spasticity treatment on overall costs remains unclear 1
The American Heart Association found that one study determined botulinum toxin plus therapy was not cost-effective compared to therapy alone, though this must be weighed against quality of life improvements 1