Managing Spasticity in MS
Spasticity is a common symptom of multiple sclerosis, affecting up to 75 percent of patients, that involves feelings of stiffness, muscle tightness, and a range of involuntary muscle spasms (sustained muscle contractions or sudden movements). Spasticity can vary in severity from mild to quite painful. Increased stiffness or muscle tone due to spasticity can lead to decreased range of motion of major joints and result in shortening of connective tissue around the joints, leading to contractures (frozen or immobilized joints) and pressure sores.
Signs of spasticity include the sensation of muscle tightness or pain, difficulty initiating movements or relaxing muscles once you’ve stopped moving them, clonus (a repetitive rhythmic beating movement of a foot or wrist), increased deep tendon reflexes, and decreased range of motion. Symptoms of spasticity may be aggravated by fatigue, stress, sudden movements or position changes, infections, extreme temperatures, humidity, pain, or tight clothing.
Spasticity is often associated with muscle weakness and primarily effects the legs. In flexor spasticity, mostly involving the hamstrings and hip flexors, the hips and knees are bent and difficult to straighten. In extensor spasticity, involving the quadriceps and adductors (muscles on the front and inside of the upper leg), the hips and knees remain straight with the legs very close together or crossed over at the ankles.
Since spasticity is so variable, treatment must be individualized and may include both pharmacological and non-pharmacological interventions. Treatment for spasticity may include exercise, medication, changes in daily activities, or a combination of these interventions. Daily stretching and other exercises are often effective in helping to relieve spasticity.
The most effective approach involves a multidisciplinary team that includes the patient, physician, nurse, and occupational and physical therapists. Sometimes total elimination of spasticity is not always the goal of treatment as some individuals with muscle weakness use the extra tone to stand and transfer. Consideration of how much spasticity is actually beneficial is important when determining treatment, and medications should be titrated accordingly. In exceptionally difficult cases, surgical intervention may be necessary.
Medications for spasticity
Many MS patients response well to oral baclofen (Linosenil®), frequently the first drug used for the management of spasticity. It is a muscle relaxant that works on nerves in the spinal cord. It is usually started at a low dose and slowly titrated up to minimize sedation and to identify the lowest effective dose. Fatigue or weakness may be side effects. Tizanidine (Zanaflex®), which may be sedating and cause dry mouth, is an effective anti-spasticity medication that calms spasms and relaxes tight muscles. It may be used alone or in combination with baclofen.
Other less-commonly used drugs include diazepam (Valium®), which is very sedating at therapeutic levels, and may be habit-forming but the effect lasts longer than baclofen; clonazepam (Klonopin®), which is a benzodiazepine used in multiple sclerosis primarily for the treatment of tremor, pain, and spasticity; gabapentin (Neurontin®), an anti-epileptic medication that has shown some success in management of spasticity; and dantrolene sodium (Dantrium®) which can damage the liver and cause blood abnormalities.
For more severe spasticity, phenol nerve block injections may be effective for up to six months and are especially useful for conditions such as severe adductor (inner thigh) spasm. Botulinum toxin (Botox®) injections have been used successfully to relieve spasticity in small muscle groups for up to three months.
Implantation of a pump to deliver Intrathecal Baclofen™ may be helpful for patients who do not respond well to oral medication or cannot tolerate the side effects. It is also an option for individuals wanting to avoid ongoing nerve injections and very small amounts of drug are required for symptom relief. Problems with the pump include pump failure, infection, and lead displacement.
Physical interventions for spasticity
Stretching and range of motion exercises may address connective tissue tightness caused by spasticity and focus on improved body alignment to decrease musculoskeletal problems. Evaluation may require the adjustment of a wheelchair seating system or use of gait and assistive devices.
Weakness may be alleviated to some extent with strengthening exercises. General conditioning can help to strengthen weak and de-conditioned muscle groups, while increasing endurance and cardiovascular conditioning. Strengthening can be achieved in a variety of ways, using free weights, machines, theraband, Swiss Balls, or aquatic exercises. Strength training can also assist with the timing of movements, depending on the strength or weakness of the agonist/antagonist muscles. Precaution must be taken, however, to avoid fatiguing muscles or the patient with excessive training. Exercise should be done in a cool environment as overheating can contribute to weakness and fatigue.
Energy expenditure and diminished fluidity of movement can be addressed by balance and coordination exercises. Swiss ball and pool exercises are very effective for balance and coordination, as are yoga and Tai Chi. Problems with co-contractions may be treated with timing exercises that focus on motor control, including yoga, Tai Chi, biofeedback, or aquatic exercises.
Pain may be alleviated or reduced by stretching, transcutaneous electrical nerve stimulation (TENS), or application of heat or cold. Ergonomic and environmental factors related to activities at work or home should be evaluated as these may be contributing to increased pain.
For more information regarding spasticity, read the “Spasticity in MS” special issue of MS in Focus published by the Multiple Sclerosis International Federation (2008).