A Letter Released to Physicians on June 2, 2006

A Comparison of Post-Stroke
Antispasmodic Treatments

Conventional treatment for post-stroke spasticity includes any of the following approaches or some combination of them: oral and intrathecal antispasmodics, local phenol or alcohol injections, physical therapy, functional electrical stimulation, and/or casting. Botulinum Toxin A (BTX-A) serves as another post-stroke antispasmodic treatment growing in popularity among physiatrists. BTX-A offers numerous advantages over other antispasmodic treatments.

BTX-A: Seven percent of post-stroke patients report side-effects such as discomfort at an injection site, headaches, and flu-like illness.¹ However, side effects are generally mild and the treatments are generally well tolerated, even by geriatric patients. One of the main hindrances to patients receiving effective BTX-A treatments is that successful treatments often require targeting smaller muscles such as the finger flexors or the toe flexors as well as specialized training to discern which specific muscles require treatment. Fortunately, you can refer your patients within driving distance of Charlotte to the private practice of Neal S. Taub, MD, physiatrist.

Oral Drugs: Oral antispasmodics such as baclofen and dantroline present risks that include drowsiness, nausea, headache, muscle weakness, and light-headedness. In geriatric care, where a percentage of patients already have impaired cognition, the sedating effects of oral antispasmodics can lead to agitation, lethargy, and falling.^2,3 Oral antispasmodics can also be habit forming. When patients ingest antispasmodics, the drugs will weaken all skeletal muscles, even though there may only be a specific group of muscles associated with the disability in question. Local injections deliver BTX-A, thereby avoiding systemic affects and weakening of unaffected muscles.

Other Injections: In a study of patients with lower-limb spasticity, a single treatment of BTX-A was compared with a percutaneous tibial nerve block by 5% phenol.⁴ At weeks 2 and 4, BTX-A showed a greater effect on muscle tone than percutaneous phenol, but effects were roughly equal at 8 weeks. Both treatments improved walking velocity and range of motion, but BTX-A created greater improvements. Adverse effects in the percutaneous phenol group included temporary but painful dysesthesia. Intramuscular phenol injections using a 2% solution allow for less side effects and better efficacy. For this reason, intramuscular phenol injections may also serve as a good choice in antispasmodic treatments, even compared to BTX-A. Both BTX-A and phenol treatments are considered and can be delivered at Dr. Taub’s physiatric practice in Charlotte.

In many cases, the patients already receiving some sort of antispasmodic treatments are the lucky ones. So many stroke survivors were not even given a complete course of stroke rehabilitation following their strokes, let alone a long-term drug regimen to deal with the functional effects.

If you know stroke survivors who suffer from spasticity or who struggle with the side-effects of oral antispasmodics, please tell them about the Physiatry practice of Neal S. Taub, MD.

References

1. 2005 Annual Meeting of the American Association of Physical Medicine and Rehabilitation, Philadelphia, Oct. 28, 2005. News release, Wake Forest University Baptist Medical Center.

2. Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology. 2001; 47(6): 295-299.

3. Mohammed I, Hussain A. Intrathecal baclofen withdrawal syndrome? A life threatening complication of baclofen pump: a case report. BMC Clin Pharmacol. 2004;4: 6.

4. Kirazli Y, On AY, Kismali B, et al. Comparison of phenol block and botulinus toxin type A in the treatment of spastic foot after a stroke: a randomized, double-blind trial. Am J Phys Med Rehabil. 1998; 77: 510-5