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Spasticity

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Hsieh JTC, McIntyre A, Townson AF, Short C, Vu V, Benton B, Wolfe DL (2019). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 7.0: p 1-135.

We would like to acknowledge the late Sandra J Connoly OT



1.0 Executive Summary

Although the majority of people with Spinal Cord Injury (SCI) have spasticity, it is not always detrimental or predictable, and may affect muscles across different joints to varying degrees.  Therefore, treatment must be carefully selected to ensure that overall function is optimized for a specific individual. To create an individualized treatment plan, clearly established clinical and functional goals combined with the use of clinical and patient-reported outcomes, validated for use in SCI, is essential.

Early in-patient rehabilitation will employ physical therapy to manage spasticity through to discharge with a post-discharge plan for ongoing management.  Spasticity related pharmacotherapies are usually needed and also initiated during hospitalization.  More invasive treatments such as surgery or neurolysis are offered to treat severe focal spasticity that remain resistant to less invasive treatment, later post-injury. Botulinum Toxin (BTX) injections are commonly used to treat persistent and severe focal spasticity.

As part of a full rehabilitation program, active exercise interventions such as hydrotherapy, Functional Electrical Stimulation (FES)-assisted cycling and walking and robot-assisted exercise are trialed and can provide short-term spasticity relief.  Other options for short-term spasticity relief include Transcutaneous Electrical Nerve Stimulation (TENS), various forms of afferent stimulation, direct spinal cord and transcranial stimulation, and drugs such as benzodiazepines for nocturnal spasticity.  However, the most common consistent management of spasticity relies on oral or intrathecal baclofen with tizanidine as a potential alternative pharmacological option.  Various other drugs, including cannabinoids, may also be effective but require additional confirmatory research. Finally, while many still hold out hope for stem cell therapy for spasticity, it has not been shown to be affective.

Gaps in the Evidence:

  • There is need for a psychometrically-validated outcome assessment for spasticity related to quality of life that probes the interactions between the spasticity, chronic pain and depression.
  • A clinically meaningful, feasible and effective outcome measures relevant to the treatment of spasticity and individual reported outcomes.
  • Confirmatory trials are needed for pharmacotherapies for people with spasticity resistant to existing first or second line treatments (baclofen (oral or intrathecal), or tizanidine).
  • Confirmatory trials are needed for non-pharmacological options to offer short term relief of spasticity for mild spasticity or as adjunct treatments to pharmacotherapies.
  • Confirmatory trials are needed to confirm that stem cell transplantation of human neural stem cells is not effective for the treatment of spasticity (and SCI in general).