Spasticity in MS is related to alterations in the normal excitory / inhibitory balance on the nerves responsible for movement, caused by lesions in central pathways. Spasticity can be both intermittent (spasms) and tonic (stiffness). Flexor and extensor spasms can be very troublesome, especially at night, adding to fatigue, and keeping two partners awake! Spasticity can also present challenges in walking, seating, and can interfere with hygiene and nursing care in bedridden patients.
The evaluation of spasticity must take function into account. In patients with weak leg muscles, the extra tone present in spasticity may actually help them to transfer, stand, and walk. Reducing spasticity may impede function, unmasking weakness. Dosing of antispasticity medication must be done carefully, with slow increments, allowing the individual to adjust gradually, with an aim of achieving a balance between relaxed tone and functional strength and ability. Often the person with MS is the best judge. Evaluation by a physiotherapist and implementation of a gentle stretch program is advisable. Yoga can be a useful gentle stretch activity. Pharmacological agents either as monotherapy, or in combination, can offer some relief. The medication plan must be tailored to the person with MS. Generally, medications should be added only 1 at a time, slowly in small increments to avoid overshooting and rendering a patient less functional than before . Baclofen is the most commonly used agent, and is the first line of treatment. Baclofen therapy must be slowly titrated, in divided doses, allowing for side effects to subside and evaluation of therapeutic effect at regular intervals. Following the introduction of antispasticity medication, adjustment side effects such as increased fatigue and GI upset tend to dissipate with time, but may return each time the dose is increased. Benzodiazepines are avoided for daytime use because of their strong sedating effect, but a small dose at bedtime may help manage night time spasms. Tizanidine is a more recent addition and the same cautions apply. Dantrolene is a potent antispasticity agent, but should not be given to anyone who is weight-bearing as it induces marked weakness. Intrathecal baclofen offers good results with relatively small doses, but the device must be maintained by trained personnel. Botulinum injections are sometimes tried, but the doses needed to achieve relaxation of large major muscle groups can often exceed safe limits. Intrathecal phenol is sometimes used in extreme cases, but it is a more permanent approach as it destroys nerve roots. Rarely, surgical intervention such as myelotomy or even cordecetomy is needed to enable basic care and positioning in someone with very advanced disability.
Notes:
All meds to be started low dose and titrated up slowly.
Dantrolene should not be used if patient is still weight bearing
Benzodiazepines should be evaluated in light of sedating effects and used with caution
Important to assess function with respect to increased tone. In patients who are using increased tone due to spasticity to stand on, care must be taken not to relax increased tone to the point of rendering them too weak to stand
Key Healthcare Professionals:
Neurologist, physiotherapist, occupational therapist, MS nurse
Symptom Management:
Implementation of a stretch program, assessment for gait, mobility and safety is important. For those with marked disability, it may be necessary to review seating. Spasticity can also be improved with medication, on review with the treating physician.
Other Resources:
An MS Society of Canada website that provides information on a variety of topics. Information is provided by a range of North American experts who respond to inquires from individuals affected by MS.
