Spasticity: A Focus on Multimodal Treatments.

With increased efforts to decrease opioid prescribing for chronic pain conditions, nonopioid analgesics and coanalgesics are being more widely utilized. Skeletal muscle relaxants (SMRs) are frequently used chronically despite a paucity of data supporting this practice. People who have really good experience with SMRs would probably argue this point but… In my mind, the best evidence in terms of using these SMR agents longer than say their FDA labeled indication might be is really for the medications like cyclobenzaprine, which has some fairly good longer term data in fibromyalgia. Unfortunately most of our longer term data with baclofen is actually in intrathecal delivery. We do have some smaller yet randomized controlled studies looking at tizanidine’s efficacy in terms of some of the different neuropathic pains as well as, believe it or not, chronic daily headache.

Potential nonpharmacologic modalities for the treatment of spasms, spasticity, or even chronic musculoskeletal pain:

• We frequently overlook transcutaneous electrical nerve stimulation; not all TENS are created equally (it’s like calling all soda “Coke”)
• Some TENS can be much more readily useful for patients who are experiencing pain due to spasm, such as neuromuscular electrical stimulation; some of the different devices will have that
• Of course, heat and ice are still tried and true. Usually for an acute injury, we’re talking ice. We typically don’t want to put heat on an acute injury for 48 to 72 hours because we don’t want to make the inflammation worse
• More people are turning to alternative modalities for pain treatment
• Acupuncture is growing in terms of its evidence base; specific points are taught to medical acupuncturists and auricular acupuncturists, for whole body muscle relaxation. You can also target certain areas of the body and certain muscle groups
• Guaifenesin: small studies have debunked its use, but many people believe it has some muscle relaxant properties. Its chemical structure is fairly similar to methocarbamol