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PubMed This is a summary of 14 peer-reviewed journal articles Updated
Neurology

Standard of Care and Managing Spasticity

At a Glance

While there is no cure for AD-HSP, a multidisciplinary approach combining focused physical therapy, oral muscle relaxants, targeted Botox injections, and advanced surgical options can effectively manage spasticity and maximize your independence.

While there are no treatments that can cure pure AD-HSP, the standard of care is focused on a multidisciplinary approach to manage symptoms and maximize your independence [1][2].

The Foundation: Physical Therapy

Physical therapy is the most impactful part of managing HSP [3]. A functional plan includes:

  • Stretching: Focuses on calves, hamstrings, and hip adductors to combat stiffness [4].
  • Strengthening: Targets the core and toe-lifting muscles (dorsiflexors) [5].
  • Balance Training: Helps prevent falls [6][7].

Managing Spasticity

Spasticity is managed in steps, starting with the least invasive options.

  1. Oral Medications: Muscle relaxants like baclofen or tizanidine [8][9]. Side effects can include drowsiness [10].
  2. Targeted Injections: Botulinum toxin A (Botox) can be injected into specific tight muscles. This “spot treats” stiffness without whole-body sleepiness [4].
  3. Advanced Interventions:
    • Intrathecal Baclofen (ITB) Pump: Delivers baclofen directly into spinal fluid, often providing better relief with fewer side effects [11].
    • Selective Dorsal Rhizotomy (SDR): A surgery that involves cutting specific sensory nerve fibers entering the spinal cord to interrupt the abnormal reflex loop causing muscle tightness [12]. This requires intensive post-operative physical therapy for several months to regain strength and function [13].
    • Orthopedic Surgery: Achilles tendon lengthening can help if muscles have become permanently shortened [14].

Treatment Path Comparison

Severity Care Team Members Common First Steps Advanced Options
Mild Neurologist, Physical Therapist PT, stretching, comfortable footwear. Occasional Botox for specific tight spots.
Moderate + Orthotist Daily stretching, oral baclofen, trekking poles. Regular Botox injections, ankle-foot orthoses (AFOs).
Significant + Neurosurgeon, Orthopedic Surgeon Consistent neuro-PT, mobility aids (walkers). ITB Pump, SDR surgery, or tendon lengthening.

Return to Home.

Common questions in this guide

What is the best type of physical therapy for AD-HSP?
The most effective physical therapy for AD-HSP includes a combination of stretching calf and hamstring muscles, strengthening the core and toe-lifting muscles, and balance training to help prevent falls.
How do doctors treat muscle stiffness and spasticity in AD-HSP?
Muscle stiffness is typically treated in steps. Doctors often start with oral muscle relaxants, move to targeted Botox injections for specific tight spots, and may consider advanced options like baclofen pumps or surgery for severe cases.
What are the side effects of oral medications for spasticity?
Oral muscle relaxants like baclofen or tizanidine can effectively reduce muscle stiffness, but their most common side effect is drowsiness or sleepiness. It is important to discuss with your doctor if these side effects outweigh the benefits for you.
Can Botox help with my walking if I have AD-HSP?
Yes, targeted botulinum toxin (Botox) injections can help improve your gait by relaxing specific tight muscles. This approach offers localized relief without the whole-body sleepiness often caused by oral medications.
What is Selective Dorsal Rhizotomy (SDR) and am I a candidate?
SDR is an advanced surgical option for significant spasticity that involves cutting specific sensory nerve fibers. A neurosurgeon can determine if you are a candidate, but it requires several months of intensive post-operative physical therapy to regain strength.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Given my gait pattern, would I be a good candidate for botulinum toxin injections to help with my walking?
  2. 2.Could you recommend a physical therapist who specializes in neuro-rehabilitation or movement disorders?
  3. 3.Based on my current symptoms, am I a candidate for Selective Dorsal Rhizotomy (SDR), and what would the intense rehabilitation look like?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (14)
  1. 1

    Inherited metabolic diseases mimicking hereditary spastic paraplegia (HSP): a chance for treatment.

    Teive HAG, Camargo CHF, Pereira ER, et al.

    Neurogenetics 2022; (23(3)):167-177 doi:10.1007/s10048-022-00688-3.

    PMID: 35397036
  2. 2

    Pathophysiology, diagnostic work-up and management of balance impairments and falls in patients with hereditary spastic paraplegia.

    Nonnekes J, van Lith B, van de Warrenburg BP, et al.

    Journal of rehabilitation medicine 2017; (49(5)):369-377 doi:10.2340/16501977-2227.

    PMID: 28471471
  3. 3

    Individual perception of environmental factors that influence lower limbs spasticity in inherited spastic paraparesis.

    Lallemant-Dudek P, Parodi L, Coarelli G, et al.

    Annals of physical and rehabilitation medicine 2023; (66(6)):101732 doi:10.1016/j.rehab.2023.101732.

    PMID: 37028193
  4. 4

    Functional effects of botulinum toxin type A in the hip adductors and subsequent stretching in patients with hereditary spastic paraplegia.

    van Lith BJH, den Boer J, van de Warrenburg BPC, et al.

    Journal of rehabilitation medicine 2019; (51(6)):434-441 doi:10.2340/16501977-2556.

    PMID: 30968942
  5. 5

    The therapeutic effects of physical treatment for patients with hereditary spastic paraplegia: a narrative review.

    Di Ludovico A, Ciarelli F, La Bella S, et al.

    Frontiers in neurology 2023; (14()):1292527 doi:10.3389/fneur.2023.1292527.

    PMID: 38093754
  6. 6

    Balance rehabilitation with a virtual reality protocol for patients with hereditary spastic paraplegia: Protocol for a clinical trial.

    Zeigelboim BS, José MR, Santos GJBD, et al.

    PloS one 2021; (16(4)):e0249095 doi:10.1371/journal.pone.0249095.

    PMID: 33793609
  7. 7

    Are clinical tests and biomechanical measures of gait stability able to differentiate fallers from non-fallers in hereditary spastic paraplegia?

    van de Venis L, Ormiston J, Bruijn S, et al.

    Gait & posture 2024; (114()):270-276 doi:10.1016/j.gaitpost.2024.10.017.

    PMID: 39437479
  8. 8

    Characteristics of Changes in Intrathecal Baclofen Dosage over Time due to Causative Disease.

    Kimoto Y, Oshino S, Tani N, et al.

    Neurologia medico-chirurgica 2023; (63(12)):535-541 doi:10.2176/jns-nmc.2022-0359.

    PMID: 37743509
  9. 9

    Baclofen and Tizanidine Adverse Effects Observed Among Community-Dwelling Adults Above the Age of 50 Years: A Systematic Review.

    Killam-Worrall L, Brand R, Castro JR, et al.

    The Annals of pharmacotherapy 2024; (58(5)):523-532 doi:10.1177/10600280231193080.

    PMID: 37589096
  10. 10

    GABAB Receptor Chemistry and Pharmacology: Agonists, Antagonists, and Allosteric Modulators.

    Nieto A, Bailey T, Kaczanowska K, McDonald P

    Current topics in behavioral neurosciences 2022; (52()):81-118 doi:10.1007/7854_2021_232.

    PMID: 34036555
  11. 11

    [Intrathecal Baclofen Therapy for Spastic Paralysis].

    Usami K

    No shinkei geka. Neurological surgery 2022; (50(6)):1353-1360 doi:10.11477/mf.1436204701.

    PMID: 36426535
  12. 12

    [Selective dorsal rhizotomy in children with hereditary spastic paraplegia].

    Smolyankina EI, Zinenko DY

    Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko 2025; (89(1)):46-51 doi:10.17116/neiro20258901146.

    PMID: 39907666
  13. 13

    Selective dorsal rhizotomy for hereditary spastic paraparesis in children.

    Sharma J, Bonfield C, Steinbok P

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2016; (32(8)):1489-94 doi:10.1007/s00381-016-3122-2.

    PMID: 27312078
  14. 14

    Improved Gait Capacity after Bilateral Achilles Tendon Lengthening for Irreducible Pes Equinus Due to Hereditary Spastic Paraplegia: a Case Report.

    Nonnekes J, Keijsers N, Witteveen A, Geurts A

    Journal of rehabilitation medicine. Clinical communications 2021; (4()):1000059 doi:10.2340/20030711-1000059.

    PMID: 34276903

This page provides educational information about managing AD-HSP spasticity. Always consult your neurologist or care team before starting or changing your treatment plan.

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