Current issues in spasticity management

BACKGROUND-Spasticity is a prominent finding among patients with spinal cord injuries and multiple sclerosis. Choosing appropriate therapy requires an individualized approach that considers the type, extent, and severity of the disorder. SUMMARY-Spasticity management is best handled by a multidisciplinary team comprising neurologists, physical medicine and rehabilitation specialists, physical therapists, occupational therapists, and orthotists. Instituting a program of regular stretching and range-of-motion exercise, along with identification and treatment of spasticity-aggravating factors, is important for all patients. Pharmacologic intervention should be considered if spasticity remains a problem. The major drugs used to treat spasticity are baclofen, tizanidine, diazepam, and dantrolene. Each of these drugs is effective in relieving excessive muscle tone and reducing spasms. Choosing among them is primarily based on consideration of their adverse event profiles. Comparative clinical trials indicate that tizanidine causes less weakness than baclofen and less sedation than diazepam. Dantrolene may not be a first-line choice for use in ambulatory patients because it causes general muscle weakness. Several other modalities may be used in patients whose spasticity is refractory to oral medication. These include local injections with botulinum toxin or phenol/alcohol, intrathecal baclofen, more extensive physical therapy, and even neurosurgical procedures. Evaluating the response of spasticity to intervention combines the subjective observations of the patient, physician, and therapists with the objective measures of muscle tone, strength, and spasm frequency. CONCLUSION-Using a multifaceted approach, most patients with spasticity can achieve reduced discomfort and improved quality of life. Additional studies are needed to determine the relative efficacy of different interventions and to develop useful instruments for monitoring therapy.