SPASTICITY is one of the most common symptoms of multiple sclerosis (MS) that is seen in up to 75% of patients. It is a complex, poorly understood symptom that is often associated with muscle weakness. Often in MS, the lower limbs are more affected by spasticity than the arms. MS-related spasticity is usually the result of increased co-contraction of muscles during movement. Increased stiffness, or tone, can lead to decreased range of motion of major joints and result in shortening of connective tissue around the joints. This, in turn, can result in contractures. Fortunately, this common symptom responds to a variety of therapeutic approaches.
Clinical indications of spasticity are highly variable and may include:
* An increase in deep tendon reflexes
* Clonus, a repetitive rhythmic beating movement of a foot or wrist
* Difficulty initiating movements
* Impaired voluntary control of muscles
* Difficulty relaxing muscles once a movement has ceased
* Sensation of muscle tightness or pain
* Flexion or extension synergy patterns
* Decreased range of motion
These clinical signs and symptoms may be aggravated by fatigue, stress, urinary tract infections, infections of other origins, and pain. Additionally, spasticity may lead to increased fatigue due to the extra energy needed to overcome excessive muscle tone during voluntary movements involved in activities of daily living.
A thorough assessment includes consideration of function in addition to increased tone, since some spasticity can be beneficial. Totally eliminating spasticity is not always a goal; some individuals with muscle weakness use their tone to stand and transfer.
Consideration of how much spasticity is actually beneficial is important when determining pharmacologic treatment, and medications should be titrated accordingly.
Treatment of spasticity will vary from patient to patient, based on the wide spectrum of factors presented. Specific interventions are determined after performance abilities and limitations are clearly identified. Long-term rehabilitation for MS-related spasticity is essential and should be initiated as early as possible. The most effective management approach involves the use of a multidisciplinary team including the physician, nurse, and occupational and physical therapists.
Spasticity usually requires both pharmacological and non-pharmacologic interventions. Oral medications are often effective, especially in the early stages of the disease. Significant changes in spasticity may signal the need to review the patient’s medications. In exceptionally difficult cases, surgical intervention may be necessary, including tenotomy, neurectomy and rhizotomy.
Pharmacologic interventions include the following:
- Oral baclofen (Linosenil®) is often used as a first line drug for management of spasticity. Many patients get good to excellent reduction in tone with this medication. It is started at a low dose and slowly titrated up to minimize sedation and to identify the lowest effective dose. Patients and family members become adept at making minor dose adjustments to control changes in tone that occur secondary to infection, stress, and other causes previously discussed. Patients may experience fatigue or weakness as a side effect. Tizanidine (Zanaflex®), which can also be sedating, is an effective anti-spasticity medication that may be used alone or in combination with baclofen. Dantrolene sodium (Dantrium®), which works at the muscle level and may cause liver toxicity, may also be considered.
- Other oral drugs used off label include diazepam (Valium®), which is very sedating at therapeutic levels, and may be habit-forming; clonazepam (Klonopin®), which is a benzodiazepine used in multiple sclerosis primarily for the treatment of tremor, pain, and spasticity; and gabapentin (Neurontin®), an anti-epileptic medication that has had some success in management of spasticity.
- For more severe spasticity, phenol nerve block injections are often effective for up to six months and are especially useful for conditions such as severe adductor (inner thigh) spasm. More recently, botulinum toxin (Botox®) injections have been used successfully for small muscle groups.
- 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 at the required dosage level. It is also an option for individuals wanting to avoid ongoing nerve injections. Very small amounts of baclofen are required for symptom relief, avoiding the side effects of systemic administration. Problems with the pump include pump failure, infection, and lead displacement.
Possible non-pharmacologic interventions are as follows:
- Stretching and range of motion exercises, following a thorough musculoskeletal exam, can treat connective tissue tightness. Posture may be a focus for improved body alignment and decreased musculoskeletal problems. This may include evaluation and adjustment of a wheelchair seating system. Gait and assistive devices may need to be further evaluated. A manual muscle test may assist in determining whether or not upper extremity strength can compensate for spasticity. This test is not always valid, since spasticity can interfere with the results.
- Problems with co-contractions can be treated with timing exercises and by focusing on motor control. One goal is to minimize fatigue through energy conservation techniques and adequate fluid intake. Yoga, Tai Chi and biofeedback may be appropriate relaxation interventions. Aquatic exercises may also be helpful.
- Weakness may be alleviated to some extent with strengthening exercises specific to those muscles identified as being weak. General conditioning can also help to strengthen weak and deconditioned muscle groups and increase 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 to avoid fatiguing muscles 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.
- Pain may be alleviated or reduced by stretching, transcutaneous electrical nerve stimulation (TENS), or thermal modalities such as cooling. Ergonomic and environmental factors should be evaluated for patients’ vocational and avocational activities as these may be contributing to increased pain.
The treatment of spasticity related to multiple sclerosis is most effective when there is a multidisciplinary approach to patient care. The patient’s abilities and limitations need to be considered, as each person’s tone and disease are unique. In some cases a single intervention will be effective, but more often a combination of non-pharmacologic and pharmacologic strategies will be needed. These interventions need to be monitored as the course of the MS changes and modifications need to be made accordingly. In rare cases of intractable spasticity, ablative surgical procedures may be required.
Spasticity by Sue Kushner, MS, PT and Kathi Brandfass, MS, PT
Clinical Bulletin / Information for Health Professionals. © 2004 National Multiple Sclerosis Society
For Further Information:
Polman CH, Thompson AJ, Murray TJ, Bowling AC, and Noseworthy JH. Multiple Sclerosis: the Guide to Treatment and Management, 6th edition. New York: Demos Medical Publishing, 2006. (updated online, 2008).