Management of spasticity

The functional impairment due to spasticity must be carefully assessed before any treatment is considered. Therapeutic intervention is best individualized to a particular patient. Basic principles of treatment to ameliorate spastic hypertonia are: 1) avoid noxious stimuli and 2) provide frequent range of motion. Therapeutic exercise, cold or topical anesthesia may decrease reflex activity for short periods of time in order to facilitate minimal motor function. Casting and splinting techniques are extremely valuable to extend joint range diminished by hypertonicity. Baclofen, diazepam and dantrolene remain the three most commonly used pharmacologic agents in the treatment of spastic hypertonia. Baclofen is generally the drug of choice for spinal cord types of spasticity, while sodium dantrolene is the only agent which acts directly on muscle tissue. Phenytoin with chlorpromazine may be potentially useful if sedation does not limit their use. Tizanidine and ketazolam, not yet available in the United States, may be significant additions to the pharmacologic armamentarium. Intrathecal administration of antispastic medications allows high concentrations of drug near the site of action, which limits side effects. This form of treatment is the most exciting recent development in the treatment of spastic hypertonia. Peripheral electrical stimulation may have limited use in diminishing tone and facilitating paretic muscles. Dorsal column stimulation via electrodes within the spinal column was initially hailed as a therapeutic advance, but has subsequently been shown to be minimally effective. Phenol injections provide a valuable transition between short-term and long-term treatments and offer remediation of hypertonia in selected muscle groups. Tenotomies and tendon transfers offer significant benefit in carefully chosen patients.(ABSTRACT TRUNCATED AT 250 WORDS)