Therapeutic intervention for the post-stroke hemiplegic with spastic hypertonia must be individualized to the patient's needs, but generally includes 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. Dantrolene sodium is the pharamacologic agent of choice in the United States for the treatment of spastic hypertonia due to stroke. It is the only available drug that acts directly on muscle tissue. Peripheral electrical stimulation may have limited use in diminishing tone and facilitating paretic muscles. 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 stroke patients, and the "SPLATT" procedure is one of the most successful rehabilitative surgeries. Achilles Tendon lengthening and release of long toe flexors may complement the SPLATT procedure in the management of the hemiplegic with spastic equinovarus.
Merritt J.Management of spasticity in spinal cord injury. Mayo Clinic Proceedings1981; 56:614-622.
2.
Katz RTManagement of spasticity. American Journal of Physical Medicine and Rehabilitation1988; 67:108-116.
3.
Castellucci VF and Kandel ERA quantal analysis of the synaptic depression underlying habituation of the gill-withdrawal reflex in Aplysia . Proceedings of the National Academy of Science, USA71:5004—5008, 1974.
4.
Castellucci VF, Carew TJ, Kandel ERCellular analysis of long-term habituation of the gill withdrawal reflex of Aplysia californica . Science202:1306-1308, 1978 .
5.
Bobath B.Adult Hemiplegia: Evaluation and Treatment. Heinemann Medical Books, London, 1970.
6.
Brunnstrom S. MovementTherapy in Hemiplegia. Harper & Row, New York, 1970.
7.
Levine MG, Kabat H., Knott M., Voss DERelaxation of spasticity by physiological technics. Archives of Physical Medicine and Rehabilitation1954; 35:214-223.
Miglietta O.Evaluation of cold in spasticity. American Journal of Physical Medicine1962; 41:148-151.
10.
Miglietta O.Electromyographic characteristics of clonus and influence of cold. Archives of Physical Medicine and Rehabilitation1964; 45:508-512.
11.
Miglietta O.Action of cold on spasticity. American Journal of Physical Medicine1973; 52:198-205.
12.
Mecomber SA , Herman RMEffects of local hypothermia on reflex and voluntary activity. Physical Therapy1971; 51:271-282.
13.
Knutsson E.On effects of local cooling upon motor functions in spastic paresis. Progress in Physical Therapy1970; 1:124-131.
14.
Lightfoot E. , Verrier M., Ashby P.Neurophysiological effects of prolonged cooling of the calf in patients with complete spinal transection . Physical Therapy1975; 55:251-258.
15.
Chan CWYSome techniques for the relief of spasticity and their physiological basis . Physiotherapy Canada1986; 38:85-89.
16.
Mills WJ, Pozos RSDecrease in clonus amplitude by topical anesthesia. Electroencephalography and Clinical Neurophysiology1985; 61:509-518.
17.
Sabbahi MA, De Luca CJ, Powers WRTopical Anesthesia: a possible treatment for spasticity. Archives of Physical Medicine and Rehabilitation1981; 62:310-314.
18.
Kaplan N.Effect of splinting on reflex inhibition and sensorimotor stimulation in treatment of spasticity. Archives of Physical Medicine and Rehabilitation1962; 43:565—569.
19.
Te Groen JA , Dommisse GEPlaster casts in the conservative treatment of cerebral palsy. South African Medical Journal July 18, 1964, pp. 502-505.
20.
Snook J.Spasticity reduction splint. American JournalOccupational Therapy1979; 33:648-651.
21.
Cherry DB, Weigand GMPlaster drop-out casts as a dynamic means to reduce muscle contracture . Physical Therapy1981; 61:1601—1603.
22.
King T.Plaster splinting to reduce elbow flexor spasticity. American Journal of Occupational Therapy1982; 36:671-673.
23.
Booth BJ, Doyle M., Montgomery J.Serial casting for the management of spasticity in the head-injured adult . Physical Therapy1983; 63:1960-1966.
24.
McPherson JJ , Becker AH, Franszczak N.Dynamic splint to reduce the passive component of hypertonicity. Archives of Physical Medicine and Rehabilitation1985; 66:249-252.
25.
Collins K., Oswald P., Burger G., Nolden G.Customized adjustable orthoses: their use in spasticity. Archives of Physical Medicine and Rehabilitation1985; 66:397-398.
26.
Otis JC, Root L., Kroll MAMeasurement of plantar flexor spasticity during treatment with tone-reducing casts. Journal of Pediatric Orthopedics1985 ; 5:682-686.
27.
Basmajian JVBiofeedback in rehabilitation: a review of principles and practices. Archives of Physical Medicine and Rehabilitation1981; 62:469-475.
28.
Wolf SL, Binder-MacLeod SA. Electromyographic biofeedback applications to the hemiplegic patient: changes in upper extremity neuromuscular and functional status. Physical Therapy1983; 63:1393-1403.
29.
Wolf SL, Binder-MacLeod SA. Electromyographic biofeedback applications to the hemiplegic patient: changes in lower extremity neuromuscular and functional status. Physical Therapy1983; 63:1404-1413.
30.
Young RR, Delwaide PJDrug therapy: spasticity. New England Journal of Medicine1981; 304:28—33, 96—99.
31.
Davidoff RAAntispasticity drugs: mechanisms of action . Annals of Neurology1985; 17:107-116.
32.
Van Hemert JCJ.A Double-blind comparison of baclofen and placebo in patients with spasticity of cerebral origin. In Spasticity: Disordered Motor Control. Feldman RG, Young RR, Koella WP, eds. Year Book Medical Publishers, Chicago , 1980.
33.
McLellan DLCo-contraction and stretch reflexes in spasticity during treatment with baclofen. Journal of Neurology, Neurosurgery, and Psychiatry1977; 40:30-38.
34.
Knutsson E. , Lindblom U., Martensson A.Plasma and cerebrospinal fluid levels of baclofen (Lioresal) at optimal therapeutic responses in spastic paresis. Journal of Neurological Science1974; 23:473-484.
35.
Faigle JW, Keberle H., Degen PHChemistry and pharmacokinetics of baclofen. In Spasticity: Disordered Motor Control. Feldman RG, Young RR, Koella WP, eds. Year Book Medical Publishers, Chicago , 1980.
36.
Koella WPBaclofen: its general pharmacology and neuropharmacology. In Spasticity: Disordered Motor Control. Feldman RG, Young RR, Koella WP, eds. Year Book Medical Publishers, Chicago, 1980.
37.
Duncan GW, Shahani BT, Young RRAn evaluation of baclofen treatment for certain symptoms in patients with spinal cord lesions. Neurology1976; 26:441-446.
38.
Sachais BA, Logue JN, Carey MSBaclofen, a new antispastic drug. Archives ofNeurology1977; 34:422-428.
39.
Hattab JRReview of European clinical trials with baclofen. In Spasticity: Disordered Motor Control. Felman RG, Young RR, Koella WP, eds. Year Book Medical Publishers, Chicago , 1980.
40.
Knutsson E. , Lindblom U., Martensson A.Lioresal and spasticity . Acta Neurologica Scandinavia1972; 48 (Supplement 51):449-450.
Khanna OPNonsurgical therapeutic modalities. In Clinical Neurourology . Krane RJ, Siroky MB, eds. Little, Brown and Co., Boston, 1979.
43.
Roussan M., Terrence C., Gromm G.Baclofen versus diazepam for the treatment of spasticity and long-term follow-up of baclofen therapy. Pharmatherapeutica1985 ; 4:278—284.
44.
Bianchine JRDrugs for Parkinson's Disease, spasticity, and acute muscle spasms. In The Pharmacological Basis of Therapeutics , 7th ed. Gilman AG, Goodman LS, Rall PW, Murad EMacmillan Publ. Co., New York, 1985.
45.
Kirkland LRBaclofen dosage: a suggestion (letter). Archives of Physical Medicine and Rehabilitation1984; 65:214.
46.
Roy CW, Wakefield IRBaclofen pseudopsychosis: case report. Paraplegia1986; 24:318-321.
47.
Terrence DV , Fromm GHComplications of baclofen withdrawal. Archives ofNeurology1981; 38:588-589.
48.
Fromm GH, Terrence CEComparison of L-baclofen and racemic baclofen in trigeminal neuralgia . Neurology1987; 37:1725-1728.
49.
Sawynok J., Dickson C.D-baclofen is an antagonist at baclofen receptors mediating antinociception in the spinal cord. Pharmacology1985; 31:248-259.
50.
Costa E., Guidotti A.Molecular mechanisms in the receptor action of benzodiazepines. Annual Review of Pharmacology and Toxicology1979 ; 19:531-45.
51.
Study RE, Barker JLCellular mechanisms of benzodiazepine action. Journal of theAmerican Medical Association1982; 247:2147-2151.
52.
Cook JB, Nathan PWOn the site of action of diazepam in spasticity in man. Journal of Neurological Science1967; 5:33-37.
53.
Verrier M., Ashby P., MacLeod S.Dizepam effect on reflex activity in patients with complete spinal lesions and in those with other causes of spasticity. Archives of Physical Medicine and Rehabilitation1977; 58:148-153.
54.
Glenn MBAntispasticity medications in the patient with traumatic brain injury . Journal of Head Trauma Rehabilitation1986 ; 1:71-72.
55.
Greenblatt DJ, Shader RI, Abernethy DRCurrent status of benzodizepines . New England Journal of Medicine1983; 309:354-358, 410-416.
56.
Van Winkle WB.Calcium release from skeletal muscle sarcoplasmic reticulum: site of action of dantrolene sodium?Science1976; 193:1130-1131.
57.
Pinder RM, Brogden RN, Speight TM, Avery GSDantrolene sodium: a review of its pharmacological properties and therapeutic efficacy in spasticity. Drugs1977; 13:3-23.
58.
Ketel WB, Kolb MELong-term treatment with dantrolene sodium of stroke patients with spasticity limiting the return of function. Current Medical Research and Opinion1984; 9:161-169.
59.
Joynt RLDantrolene sodium: long-term effects in patients with muscle spasticity . Archives of Physical Medicine and Rehabilitation1976; 57:212-217.
60.
Meyler WJ, Bakker H., Kok JJ, Agoston S., Wesseling H.The effect of dantrolene sodium in relation to blood levels in spastic patients after prolonged administration. Journal of Neurology Neurosurgery and Psychiatry1981; 44:334-339.
61.
Hennies OLA new skeletal muscle relaxant (DS 103-282) compared to diazepam in the treatment of muscle spasm of local origin. Journal of International Medical Research1981; 9:62-68.
62.
Davies J., Quinlan JESelective inhibition of feline dorsal hom neurons to noxious cutaneous stimuli by tizanidine and noradrenaline: involvement of alpha-2 adrenoceptors . Neuroscience1985; 16:673-682.
63.
Young RR, Shahani BTSpasticity in spinal cord injured patients. In Management of Spinal Cord Injuries. Bloch RF, Basbaum M, eds. Williams & Wilkins , Baltimore, 1986.
64.
Knutsson E. , Martensson A., Gransberg L.Antipyretic and anti-spastic effects induced by Tizanidine in patients with spastic paresis. Journal of Neurological Science1982; 53:187-204.
65.
Medici M., Pebet M., Ciblis D.A double-blind, long-term study of tizanidine in spasticity due to cerebrovascular lesions. Current Medical Research and Opinion1989; 11:398-407.
66.
Bes A., Eyssette M., Pierrot-Deseilligny E., et al. A multi-centre, double-blind trial of tizanidine, a new antispastic agent, in spasticity associated with hemiplegia. Current Medical Research and Opinion1988; 10:709-718.
67.
Stien R., Nordal HJ, Oftedal SI, Slettebo M.Treatment of spasticity in multiple sclerosis: a double-blind clinical trial of a new anti-spastic drug tizanidine compared with baclofen. Acta Neurologica Scandinavia1987; 75:190-194.
68.
Hassan N., McLellan DLDouble-blind comparison of single doses of DS103—282, baclofen, and placebo for suppression of spasticity. Journal of Neurology Neurosurgery, andPsychiatry1980; 43:1132-1136.
69.
Baker LL, Yeh C., Wilson D., Waters RLElectrical stimulation of wrist and fingers for hemiplegic patients . Physical Therapy1979; 1495-1499.
70.
Levine MG, Knott M., Kabat H.Relaxation of spasticity by electrical stimulation of antagonistic muscles . Archives of Physical Medicine and Rehabilitation1952; 11:668-673.
71.
Alfieri V.Electrical treatment of spasticity: reflex tonic activity in hemiplegic patients and selected specific electrostimulation. Scandinavian Journal of RehabiltationMedicine1982; 14:177-182.
72.
Vodovnik L. , Bowman BR, Winchester P.Effect of electrical stimulation on spasticity in hemiparetic patients. International Rehabilitation Medicine1984; 6:153-156.
73.
Gracanin E.Functional electrical stimulation in external motor control of motor activity and movements of paralysed extremities. International Rehabilitation Medicine1984; 6:25-30.
74.
Petajan JHSural nerve stimulation and motor control of tibialis anterior muscle in spastic paresis. Neurology1987; 37:47-52.
75.
Vodovnik L., Rebersek S., Valencic V., Stefanovska A., Stefnacic M., Gros N., Jelnikar T.Functional improvement of pathological neuromuscular systembs by means of electrical stimulation. In Proceedings of the Rehabilitation Engineering International Seminar, 1982. July 16-17, 1982, Tokyo, Japan.
76.
Walker BJModulation of spasticity: prolonged suppression of a spinal reflex by electrical stimulation. Science1982; 216:203-204.
77.
Waters RLThe enigma of "carry-over."International Rehabilitation Medicine1984; 6:9-12.
78.
Dimitrijevic MR, Sherwood AMSpasticity: medical and surgical management . Neurology1980; 30:19-27.
79.
Albert A., Andre JMState of the art of functional electrical stimulation in France. International Rehabilitation Medicine1984; 6:13-18.
80.
Waters RL, McNeal DR, Faloon W., Clifford B.Functional electrical stimulation of the peroneal nerve for hemiplegia . Journal of Bone and Joint Surgery1985; 67A:792—793.
81.
Khalili AA, Harmel M., Forster S., Benton JGManagement of spasticity by selective peripheral nerve block with dilute phenol solutions in clinical rehabilitation. Archives of Physical Medicine and Rehabilitation1964; 45:513-519.
82.
Khahali AA, Betts Hbb.Peripheral nerve block with phenol in the management of spasticity. Journal of theAmerican Medical Association1967; 200:1155-1157.
83.
Khalili AAPhysiatric management of spasticity by. phenol nerve and motor point block . In Current Therapy in Physiatry. Ruskin AP, W. B. Saunders, Philadelphia, 1984 .
84.
Easton Jkm , Ozel T., Halpern D.Intramuscular neurolysis for spasticity in children. Archives of Physical Medicine and Rehabilitation1979; 60:155-158.
85.
Halpern D., Meelhuysen FEPhenol motor point block in the management of muscular hypertonia . Archives of Physical Medicine and Rehabilitation1966; 45:513-519.
86.
Wood KMThe use of phenol as a neurolytic agent. Pain1978; 5:205-229.
87.
Petrillo CR , Chu DS, Davis SWPhenol block of the tibial nerve in the hemiplegic patient. Orthopedics1980; 3:871-874.
88.
Garland DE, Lilling M., Keenan MAPercutaneous phenol blocks to motor points of spastic forearm muscles in head-injured adults. Archives of Physical Medicine and Rehabilitation1984; 65:243-245.
89.
McComas AJ, Kereshi S., Manzano G.Multiple innervation of human muscle fibers. Journal of the NeurologicalSciences1984; 64:55-64.
90.
Garland DE, Lucie RS, Waters RLCurrent uses of open phenol nerve block for adult acquired spasticity . Clinical Orthopaedics and Related Research1982; 165:217—222.
91.
Keenan MAE.The orthopedic management of spasticity. Journal of Head Trauma Rehabilitation1987; 2:62—71.
92.
Glenn MBUpdate on pharmacology. Journal of Head Trauma Rehabilitation1986; 1:72-74.
93.
Medical News .Journal of theAmerican Medical Association1983; 249:1807.
94.
Botulinum toxin for ocular muscle disorders. Medical Letter1990; 32:100-102.
95.
Smith CW, Leventhal L.Surgical treatment of lower extremity deformities in adult head-injured patients . Journal of Head Trauma Rehabilitation1987 ; 2:53-567.
96.
Treanor WJImprovement of function in hemiplegia after orthopaedic surgery. Scandinavian Journal of Rehabilitation Medicine1981 ; 13:123-135.
97.
Pinzur MSSurgery to achieve dynamic motor balance in adult acquired spastic hemiplegia. Journal of HandSurgery1985; 10A:547-553.
98.
Pinzur MS, Wehner J., Kett N., Trilla M.Brachioradialis to finger extensor tendon transfer to achieve hand opening in acquired spasticity. Journal of HandSurgery1988; 13A:549-552.
99.
Waters RLUpper extremity surgery in stroke patients. Clinical Orthopaedics and Related Research1978; 131:30-37.
100.
Keenan MAE , Abrams RA, Garland DE, Waters RLResults of fractional lengthening of the finger flexors in adults with upper extremity spasticity Journal of HandSurgery1987; 12A:575-581.
101.
Pinzur MS, Sherman RS, Dimonte-Levine PDTriceps spasticity in traumatic hemiplegia: diagnosis and treatment . Arch Phys Med Rehabil1987 ; 68:446—449.
102.
Waters RL, Perry J., Garland.Surgical correction of gait abnormalities following stroke. Clinical Orthopaedics and Related Research1978; 131:54-63.
103.
Waters RL, Frazier J., Garland DE, Jordan C., Perry J.Electromyographic gait analysis before and after operative treatment for hemiplegic equinus and equinovarus deformity. Journal of Bone andJoint Surgery1982; 64A:284-288.
104.
Sindou M., Pregelj R., Boisson D., Eyssette M., Goutelle A.Surgical selective lesions of nerve fibers and myelotomies for modifying muscle hypertonia. In Recent Achievements in Restorative Neurology: Upper Motor Neuron Function and Dysfunction. Eccles J, Dimitrijevic MR, eds. Karger, Basel, 1985.
