Management of Focal Upper Limb Spasticity

Introduction

Focal upper limb spasticity is a condition that requires a comprehensive treatment approach, focusing on improving function and relieving discomfort, rather than just reducing muscle tone, as recommended by the American Academy of Family Physicians 1

Botulinum toxin injection is a recommended treatment option for patients with focal upper limb spasticity due to traumatic brain injury, as it effectively reduces muscle tone without causing systemic side effects, according to the American Academy of Family Physicians 1
OnaBoNT-A, incoBoNT-A, or aboBoNT-A are safe and effective options for upper extremity spasticity, reducing muscle tone and improving passive function (range of motion) 1
Tizanidine is a first-line oral medication for post-stroke spasticity, particularly effective for chronic stroke patients with spasticity and pain without loss of motor strength, with high evidence supporting its effectiveness, and should be started with a low dose (2mg once daily) and gradually titrated up, as recommended by the American Geriatrics Society 2, 3
Baclofen is an alternative first-line oral medication, a GABA-B receptor agonist effective for spasticity, but may cause significant sedation and have less impact on spasticity in stroke compared to other conditions, with moderate evidence supporting its effectiveness, and should be avoided for abrupt discontinuation to prevent withdrawal complications 2, 4
Dantrolene should be considered when cognitive side effects must be minimized, starting at low doses (25mg daily) and titrating slowly, with limited trial data in stroke patients, and low evidence supporting its effectiveness 2

Botulinum toxin has established efficacy in reducing upper limb spasticity, with significant reductions in pain intensity and brush-evoked allodynia compared to placebo in a double-blind trial, as reported by 5
The treatment can improve passive function and range of motion, although evidence for improvement in active function is less robust, according to the American Academy of Family Physicians 1
Functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), resistance training, and lower extremity ergometer training are recommended over passive interventions for improving functional outcomes in patients with post-stroke spasticity, with low to moderate evidence supporting their effectiveness 2

Expiratory muscle training is recommended for patients with neuromuscular weakness and impaired cough, as it improves peak expiratory pressure, which may benefit cough effectiveness, as suggested by the American College of Chest Physicians 6
Positioning, passive stretching, and range-of-motion exercises should be performed several times daily to help reduce spasticity in patients with post-stroke spasticity, with moderate evidence supporting their effectiveness 2
Gentle stretching and mobilization techniques should be implemented to prevent contractures, with active range of motion increased gradually while restoring alignment and strengthening weak muscles 7
Orthotic management, such as knee-ankle-foot orthoses, can prevent knee buckling during ambulation 8
Splinting and serial casting can be used for developing contractures, with low to moderate evidence supporting their effectiveness 2

The effects of botulinum toxin wear off over time, requiring repeated injections, as reported by 1
Benzodiazepines, such as diazepam, have limited efficacy for persistent spasticity and are not recommended as first-line therapy due to sedation, tolerance, and dependence issues, but may be justified for short-term use when anxiety and muscle spasm coexist, according to the American Geriatrics Society 9
Abrupt discontinuation of baclofen can cause serious withdrawal, with high evidence supporting the importance of gradual tapering 2
Using diazepam during stroke recovery period due to negative effects on recovery can lead to poor outcomes, with high evidence supporting its potential harm 2
Abrupt discontinuation of intrathecal baclofen can lead to withdrawal syndrome, which can be life-threatening if not promptly recognized and treated, as reported by Anaesthesia in 2020 10

The primary focus of treatment should be on improving function and relieving discomfort, not just reducing muscle tone, to effectively manage muscle spasms in quadriplegics, as recommended by 9
Focus treatment on improving pain, skin hygiene, and function rather than just reducing muscle tone, with moderate evidence supporting the importance of a comprehensive approach 2, 3
Regularly assess skin integrity as spasticity can contribute to pressure ulcer development, with high evidence supporting the importance of regular assessment 2, 11
Identify and treat factors that can worsen spasticity (skin pressure sores, fecal impaction, urinary tract infections, and bladder stones), with moderate to high evidence supporting the importance of addressing these factors 7
Analgesics (acetaminophen or ibuprofen) can be used if no contraindications, and subacromial corticosteroid injections can be considered if pain is related to rotator cuff or bursa inflammation, as recommended by 7