Spasticity & Spasms After SCI: Causes, Treatments, and What Can Help

Spasms. They wake you up at night. They throw you out of your chair. They make transfers dangerous and sleep impossible. They're painful, exhausting, and unpredictable. And yet — they're also a sign that your nervous system is alive below your injury, and for many people with incomplete injuries, they coexist with function in complicated ways.

This covers what causes spasms, every treatment option, and practical knowledge from people who've been managing spasticity for years.

What Spasticity Actually Is

Spasticity is involuntary muscle stiffness and spasms caused by damage to the upper motor neurons — the pathways from the brain down through the spinal cord that normally regulate muscle tone. When those regulatory signals are disrupted by SCI, the muscles below the injury lose their inhibitory control and can fire spontaneously or in exaggerated response to stimulation.

Spasticity differs from flaccidity. People with upper motor neuron (UMN) injuries (most cervical and thoracic injuries) develop spasticity — increased tone, hyperactive reflexes, spasms. People with lower motor neuron (LMN) injuries (cauda equina, conus) more often have flaccid paralysis — floppy muscles that don't spasm.

Spasticity typically develops weeks to months after injury as spinal shock resolves — not immediately.

What Triggers Spasms

This is critical knowledge. Almost any noxious stimulus below the injury level can trigger spasms — and identifying the trigger is often the most effective treatment.

• Bladder issues — full bladder, kinked catheter, UTI. The most common trigger. If your spasms suddenly worsen, check your bladder first.
• Bowel issues — constipation, impaction, gas
• Pressure injuries — even a small wound you can't feel
• Ingrown toenails, cuts, skin irritation
• Tight clothing or shoes
• Infections — UTI, respiratory infection, any systemic infection
• Temperature changes — especially cold
• Fatigue and overexertion
• Stress and anxiety
• Position changes — certain positions trigger spasms; learning yours takes time
• Sexual arousal

Spasticity Isn't Always Bad

This is counterintuitive but important. Some degree of spasticity can be functionally useful:

• Leg spasticity provides tone that makes standing, pivoting, and some transfers easier
• Spasticity maintains muscle bulk and bone density, reducing atrophy
• Spasms can serve as a warning signal for problems below the injury
• Some people use their spasms strategically — triggering a leg extension to assist with a transfer

The goal isn't zero spasticity — it's functional spasticity. Treat what interferes with your life; don't over-treat what might be helping.

Stretching & Positioning: The Foundation

Before any medication, stretching is the most evidence-based intervention for managing spasticity. Daily, consistent stretching reduces tone, prevents contractures, and can reduce the frequency and intensity of spasms over time.

Key muscle groups to stretch: Hip flexors, hamstrings, calf/Achilles, hip adductors, wrist and hand flexors (for cervical injuries). Each major muscle group should be held for 30–60 seconds, repeated 2–3 times, at least once daily.

Standing programs: Regular standing — whether in a standing frame, standing wheelchair, or with assistance — provides prolonged stretch through the lower extremities and has documented effects on reducing spasticity and maintaining bone density.

Positioning in bed: Proper neutral positioning during sleep reduces nighttime spasms. Side-lying with a pillow between the knees, avoiding prolonged hip or knee flexion.

What the community says: Many people with SCI report a regular stretching routine matters more than their medications. "Twenty minutes of stretching every morning changed my whole day" is a common refrain. Consistency matters more than duration.

Baclofen (Oral): The First-Line Drug

Baclofen (Lioresal) is the most commonly prescribed drug for SCI spasticity. It works by binding to GABA-B receptors in the spinal cord, inhibiting the hyperactive reflex activity that causes spasms.

What it does well: Reduces spasm frequency and severity, reduces clonus, improves range of motion, and can significantly improve sleep quality when spasms disrupt sleep.

The side effect problem: Sedation, weakness, fatigue, cognitive fog, and dizziness are common — and dose-dependent. Finding the dose that manages spasticity without making you too tired or weak to function is an ongoing calibration. Most people take the majority of their dose at night.

Tolerance: Over time, many people find baclofen becomes less effective. Dose creep — gradually needing higher doses for the same effect — is common. This is one reason the intrathecal pump eventually becomes attractive for many people.

Never stop abruptly: Baclofen withdrawal is serious and potentially life-threatening, causing rebound spasticity, seizures, high fever, and hallucinations. Always taper slowly.

Dosing: Usually started at 5mg 3x daily and titrated up. Maximum recommended dose is 80mg/day, though some people are prescribed more. Many find 40–60mg/day the sweet spot before side effects become limiting.

Tizanidine (Zanaflex): The Alternative

Tizanidine works differently from baclofen — it's an alpha-2 adrenergic agonist that reduces excitatory input to motor neurons. It has comparable efficacy to baclofen for spasticity and may have slightly less weakness as a side effect.

Community preference: Many people find tizanidine better for daytime use — less sedating than baclofen for some. Others find the opposite. The side effect profiles overlap significantly (sedation, weakness, dry mouth).

Liver effects: Tizanidine can affect liver function. Liver function tests are recommended for people on long-term tizanidine.

Many people use both — baclofen at night, tizanidine during the day, or baclofen as a baseline with tizanidine for breakthrough spasticity.

Diazepam & Clonazepam

Benzodiazepines have muscle-relaxant properties in addition to their anxiolytic effects and are sometimes used for SCI spasticity. Diazepam (Valium) was one of the original spasticity treatments.

They work, but tolerance, dependence, cognitive impairment, and interaction risks make them a poor long-term choice. Some people use them for breakthrough spasms or nighttime when nothing else works. Legitimate tool, real risks — requires careful management.

Intrathecal Baclofen Pump (ITB)

An ITB pump is a surgically implanted device — roughly hockey puck-sized, placed in the abdomen — that delivers baclofen directly into the spinal fluid through a catheter. Because the drug reaches the target directly, the doses needed are 100–1000 times smaller than oral doses, dramatically reducing systemic side effects.

Who it's for: People with severe spasticity not adequately controlled by oral medications, or where oral doses required for control cause intolerable side effects. Usually considered after oral medications have been tried and found inadequate.

What it changes: For many people with severe spasticity, ITB is transformative. Spasms that were waking them up every hour, making transfers dangerous, or causing constant pain can be dramatically reduced. The ability to turn the dose up or down allows fine-tuning over time.

What it requires: The pump needs to be refilled every 3–6 months (an outpatient procedure). The battery lasts 5–7 years, then requires surgical replacement. A neurologist or physiatrist programs the pump.

The serious risk: Pump malfunction or catheter kinking can cause baclofen withdrawal — a medical emergency. Anyone with an ITB pump should carry a wallet card explaining this to emergency providers. Family and caregivers should know the signs.

Botox Injections for Focal Spasticity

Botulinum toxin injected into specific overactive muscles temporarily paralyzes them (3–6 months per injection). It's ideal when spasticity is focal — a specific muscle group causing problems — rather than widespread.

Common uses in SCI: calf/foot spasticity causing equinus foot deformity, hip adductor spasticity interfering with hygiene or positioning, wrist/hand flexor spasticity in cervical injuries.

Repeated injections are required. Insurance coverage is variable and often requires prior authorization documentation.

Cannabis for Spasticity

Cannabis — particularly THC — has well-documented muscle-relaxant and anti-spasticity effects. Many people with SCI report it reduces both the frequency and intensity of spasms, often more palatably than oral baclofen.

Nabiximols (Sativex), a standardized THC:CBD oromucosal spray, is approved in many countries specifically for MS spasticity. Studies support its efficacy for spasm frequency and severity. It's not yet FDA-approved in the US but is available in Canada and Europe.

For people in legal states, many find evening cannabis use significantly reduces nighttime spasms and improves sleep. The combination with lower-dose baclofen is commonly reported as more effective and better-tolerated than high-dose baclofen alone.

Cold, Heat & TENS

Cold/ice: Reduces spasticity temporarily by slowing nerve conduction. Ice packs applied to spastic muscle groups for 20 minutes before activity or therapy can reduce tone. Works for some, triggers spasms for others — individual response varies.

Heat: Warm water (aquatic therapy) consistently reduces spasticity during and shortly after. A warm shower or bath before the day begins is one of the most widely reported effective tools in the community.

TENS: Applied above or at the injury level, transcutaneous electrical nerve stimulation has some evidence for reducing spasticity. Low risk, worth trying.

Phenol & Nerve Blocks

Phenol injected near a motor nerve or into a motor point can denervate specific muscles for months to years. It's more permanent than Botox but less predictable. Used for severe focal spasticity when Botox isn't adequate or isn't feasible.

Surgical Options

Selective dorsal rhizotomy (SDR) — Cutting selected sensory nerve roots to reduce reflex-driven spasticity. More commonly used in pediatric cerebral palsy but occasionally in SCI. Permanent and irreversible — only considered in very specific cases.

Tendon lengthening — Surgical lengthening of contracted tendons in chronic severe spasticity where contractures have developed. Addresses the consequence of spasticity rather than the cause.

What the Community Has Figured Out

• "Track your triggers." Keeping a simple log of when spasms are worst — time of day, what you've done, what you ate, bladder status — reveals patterns that medication never will.
• "A warm shower first thing beats everything else." Consistently the most-cited non-medication intervention across the SCI community. The combination of heat and the sensory input seems to reset tone for hours.
• "Check your bladder before you reach for a pill." How many "bad spasm days" turn out to be related to a UTI, constipation, or a kinked catheter tube? Most people with SCI eventually develop this reflex automatically.
• "Baclofen at night, stretching in the morning." The combination is more effective than either alone. Many people take their full baclofen dose at night, stretch for 20 minutes after waking, and have dramatically less daytime spasticity than when they were trying to split doses throughout the day.
• "Spasms before activity aren't the same as spasms at rest." A leg extension spasm during a transfer is different from a 3am spasm that won't stop. The former you can use. The latter you treat aggressively.

Sources & Further Reading

This page combines lived SCI experience with published clinical guidance, including:

• Spasticity and Spinal Cord Injury — Model Systems Knowledge Translation Center (MSKTC) (see the factsheet library)
• Today's Care — Christopher & Dana Reeve Foundation
• Clinical Practice Guidelines library — Consortium for Spinal Cord Medicine Clinical Practice Guidelines (Paralyzed Veterans of America)

SCI.help articles are information, not medical advice. Practice varies by injury level, provider, and institution — always confirm specifics with your own care team.