Contractures, skeletal muscle spasms and spasticity in palliative care
Skeletal muscle spasms (an involuntary contraction of muscle) and spasticity (an involuntary contraction of muscle triggered by movementBhimani, 2014) can co-exist and be associated with functional impairment and pain in patients with palliative care needs, particularly those with upper motor neurone disorders (eg multiple sclerosis, spinal cord injury, acquired brain injury, motor neurone disease). Contractures (fixed tightening of muscles, tendons and skin) can occur separately or alongside spasms and spasticity, and can result in reduced joint mobility, functional decline and painHarvey, 2017Skalsky, 2012.
Contractures generally do not respond to drug therapy—seek expert advice for the prevention and management of symptomatic contractures.
To manage skeletal muscle spasm or spasticity in palliative care, use:
1baclofen 5 mg orally, 3 times daily. Increase total daily dose by 10 to 15 mg every 3 days to optimum response (maximum total daily dose of 100 mg in 3 divided doses)1. Review response after 6 to 8 weeks; long-term therapy may be required. If symptoms do not improve with the maximum tolerated dose, stop baclofen by reducing the dose over 2 weeks to avoid withdrawal symptoms baclofen
OR
2clonazepam 0.5 mg orally or sublingually, twice daily2. Review response after 4 weeks; long-term therapy may be required. If symptoms do not improve with the maximum tolerated dose, stop clonazepam by gradually reducing the dose, to avoid withdrawal symptoms, according to the approach outlined in Weaning benzodiazepines, zolpidem or zopiclone in the Addiction guidelines clonazepam
OR
2diazepam 2 to 5 mg orally, up to 3 times daily. Review response after 4 weeks; long-term therapy may be required. If symptoms do not improve with the maximum tolerated dose, stop diazepam by gradually reducing the dose, to avoid withdrawal symptoms, according to the approach outlined in Weaning benzodiazepines, zolpidem or zopiclone in the Addiction guidelines. diazepam
If baclofen is ineffective alone, consider adding clonazepam or diazepam (at the dosage above).
If skeletal muscle spasm or spasticity does not respond to treatment, seek specialist palliative care advice. Specialist treatments may include cannabinoids or botulinum toxin type A. Botulinum toxin type A reduces muscle spasticity and spasticity-associated pain in upper motor neurone disorders.