After a Stroke: Medications to Reduce Arm Spasticity

From the WebMD Archives

When it comes to stroke rehabilitation, one medication doesn’t fit all. Your stroke rehab team will work with you to find out which medications, if any, can improve stiffness after a stroke. It's important to remember these medications are not a cure. They are ongoing treatments that relieve the symptoms of spasticity.

"There are no medications that have been well proven -- in large, well-designed clinical trials -- to directly help with motor rehabilitation beyond their effect on spasticity," says Rebecca Gottesman, MD, PhD, Gottesman is assistant professor of cerebrovascular neurology at Johns Hopkins Hospital in Baltimore.

When spasticity occurs, muscles remain tight. This can cause pain, abnormal posture, and uncontrollable movements. Nearly one out of every three patients may have spasticity after a stroke. The spasticity can occur anywhere in the body, but it is most common in the arm. Activities like dressing and eating may become very difficult.

But a variety of treatments, including medications, can help. Which therapies you use depends on the extent and severity of your spasticity. You may need more than one type to manage the problem. And for best results during stroke rehab, medications in combination with therapy such as stretching and strengthening exercises work best and are typically the first line of treatment. Without daily physical rehab, the muscles will remain contracted and joints become immobile.

Oral Medication After a Stroke

If you have severe abnormal tone - an abnormal increase in muscle tension and a reduced ability of the muscle to stretch -- and all limbs are involved, oral medications may be the best option, Bogey says. These medications act on many muscle groups at the same time. However, they can also cause systemic side effects like sleepiness. "Patients tend to get sedated before they see benefits from these medications," Stein says. “It’s not that they’re not of some value, but the side effects generally outweigh the clinical benefits."

Oral medications for spasticity include medications such as these:

  • Baclofen (Lioresal) relaxes muscles by acting on the central nervous system. It can decrease muscle spasms, tightness, and pain and improve range of motion. Side effects may include confusion or hallucinations, slight sedation compared to other treatments , loss of muscle tone or coordination, and weakness in unaffected muscles.
  • Tizanidine hydrochloride (Zanaflex) reduces spasticity by blocking nerve impulses. However, it does not lessen muscle strength. Because it lasts for a short time, tizanidine is best used only when you need it for relief or to be able to complete certain activities. Side effects may include low blood pressure, dry mouth, and sleepiness.
  • Benzodiazepines (Valium and Klonopin) relax muscles and decrease spasticity for a brief time. They do this by acting on the central nervous system. Side effects may include drowsiness, muscle weakness, mental impairment, or dependence.
  • Dantrolene sodium (Dantrium) blocks signals that make muscles contract. This may reduce muscle tone. Side effects may include depression, weakness, drowsiness, nausea, vomiting, dizziness, diarrhea, and rarely liver failure.

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Injections to Reduce Arm Spasticity After a Stroke

Is your spasticity limited to only one arm? If so, nerve block injections may be the best option for you. That’s because they’re effective and have fewer side effects than oral medications. Two main types of injections are commonly used: botulinum toxin and phenol.

Botulinum toxin (Botox or Myobloc) is a neurotoxin that works by blocking chemicals that make muscles tight. These injections usually improve muscle stiffness within two to four weeks. You may need more than one shot, although too many injections may be counterproductive, says Joel Stein, MD, professor and chief of the division of rehabilitation medicine at Weill Cornell Medical College in New York City.

Ross Bogey, DO, assistant professor of physical medicine and rehabilitation at the Rehabilitation Institute of Chicago, says that botulinum toxin may indirectly help with stroke rehab, especially for patients who can’t undergo therapy because of spasticity in their wrist and hands. "We often use Botox to reduce spasticity so patients can participate in therapy that leads to ... recovery," he says.

Botulinum toxin is approved by the FDA for use in upper extremity spasticity. The most common side effects of botulinum toxin are:

  • soreness at the injection site or affecting your whole body
  • weakness in muscles that have been injected
  • trouble swallowing
  • a red rash

Baclofen can be given as an injection within the space surrounding the spinal cord also known as intrathecal injections. However, this this requires surgical implantation of a pump that delivers the drug to the spinal cord. Side effects may include:

  • Drowsiness
  • Nausea or vomiting
  • Headache or dizziness
  • Loose muscles
  • A problem with the catheter delivering the drug

Phenol is an alcohol injection that acts more quickly and may last longer. It provides relief from spasticity by eliminating certain nerve pathways.

The most common side effects of phenol are:

  • pain during injection
  • burning or tingling sensation at the injection site
  • swelling in the injection area

When Spasticity Persists After a Stroke

Surgery is a last resort in severe cases.

"If someone has significant ongoing pain despite trying multiple injections, oral medications, or intrathecal medications, they might need to consider surgery to the tendons, for instance, to improve tone in that limb," Gottesman says. The same is true, she tells WebMD, for a patient who can’t tolerate any of the medications.

Surgery might be used in cases where someone has developed a permanent shortening of the tendon and treating the spasticity alone won't help, Bogey says. "You have to lengthen the tendons to get them back into a functional position," he says. In other cases, surgery may be used to cut and transfer tendons or to sever the nerve muscle pathway.

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New Treatments for Stroke in the Future

Researchers are studying how medicine might improve relearning motor skills after a stroke or the ability of the brain to take over parts of the brain damaged by a stroke, says Gottesman. "And, in the days after a stroke, we may one day be able to give a neuroprotectant, which could reduce the extent of brain injury related to stroke and would ultimately improve stroke recovery."

But it’s unlikely that a single drug will ever address all the problems associated with stroke, Bogey says. "Strokes are complicated and many types of neurotransmitters are typically involved."

WebMD Feature Reviewed by Michael W. Smith, MD on June 01, 2012

Sources

SOURCES:

Excite: “Spasticity.”

Sommerfeld D. Stroke, 2004; vol 35: pp 134-139.

Ross Bogey, DO, attending physiatrist, stroke rehabilitation program; RIC assistant professor, physical medicine and rehabilitation, Chicago.

National Stroke Association: “Spasticity and Paralysis: Treatment Options.”

Rebecca Gottesman, MD, PhD, assistant professor, cerebrovascular neurology; director, clinical research, Bayview Neurology, Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Baltimore.

Joel Stein, MD, professor and chief, division of rehabilitation medicine, Weill Cornell Medical College; physiatrist-in-chief, New York Presbyterian Hospital, New York.

Stroke Connection, May/June 2011.

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