Symptom Management

Treatment and Management of Spasticity in MS

By Claude Oster, D.O., P.L.
It is estimated that 80 percent of persons with multiple sclerosis experience the symptom called spasticity. A recent study indicates that about one million people in the United States have MS; therefore, about 800,000 thousand people with MS live with some degree of spasticity.
 
Spasticity is a hallmark of neurologic diseases that affect the central nervous system. Spasticity involves stiffness and/or muscle spasms, which are sustained muscle contractions or sudden jerky movements. It can range from a mild feeling of tightness in your muscles to severe, painful, uncontrolled spasms or muscles cramps. It may cause feelings of pain and tightness around your joints and back. And it can be aggravated by external stimuli, such as sudden movements, temperature changes, position changes, tight clothing, or infections.
 
Without treatment, spasticity can cause:
 
• Pressure sores – open wounds that form because of friction
• Pain and fatigue – your spastic muscle is working continuously without any rest
• Sleep disturbance – restless leg syndrome may be a disturbing feature
• Joint contracture – causing joint deformities and difficulties with positioning and pain
• Ambulation difficulties – if the muscles in back of the legs [hamstrings] and the muscles of the upper thighs are affected, then the knees and hips are bent and may not be able to straighten). If the quadriceps and the muscles in front and inside the upper legs are in spasms, the hips and knees stay straight with the legs closed or crossed over.
• Additional difficulties with positioning, mobilizing a wheelchair, and transferring to and from beds, toilets, and cars.
 
Cause of Spasticity

Gamma-aminobutyric acid (GABC) is a neurotransmitter in your nervous system. Impulses to and from your nervous system are chemically transmitted by GABA. An absence or deficiency of it allows contractions or spasms, because your nervous system isn’t able to send out a message for your muscles to relax.
 
Treatment
 
After evaluation, a physician will typically  recommend physical and occupational therapy to attempt to relax and stretch the muscles. These can frequently help to relieve spasms and reduce pain. However, you must be careful not to overwork the muscles and cause fatigue. Occasionally splinting and bracing may be beneficial.
 
Oral medication may be recommended as well. The most common are baclofen, tizanidine, diazepam, and dantrolene. These can have various side effects, ranging from drowsiness, to dry mouth, to liver toxicity. Discuss the potential side effects of each medication with your doctor to determine which will give you the most benefit with the least risk.
 
Injectable Medications
 
Botulism toxin (Botox, Dysport) has been useful when dealing with focal or localized spasticity, such as "clenched fist,"  seen usually with strokes. This type of treatment is unfortunately not appropriate for patients with widespread spasticity.
 
The most effective treatment for widespread spasticity will be GABA replacement in the spinal fluid through a baclofen pump. Because most oral medications will have side effects, such as sedation and cognitive changes, introducing GABA in the spinal fluid will minimize those side effects.
 
GABA replacement in the form of baclofen only requires a miniscule dosage, as opposed to oral meds. The average oral dose of oral baclofen is 20 to 80 milligrams per day, while a more effective response will only require 100 to 200 micrograms per day when injected into the spinal fluid. This represents a reduction of the dosage by the thousands, but with a better response.
 
There is a test procedure used to determine if a baclofen pump will be helpful. After a spinal tap and injecting a small test dose of baclofen, your spasticity is monitored for at least four hours. If the test demonstrates a decrease in spasm and pain, you are considered a candidate for a baclofen pump.

Pump insertion is done on a different day, and it is usually done on an outpatient basis. The procedure involves a neurosurgeon placing the small pump in a pouch in the lower abdomen with a catheter anchored in the spine.
 
The pump is a small computer and a reservoir for baclofen, and will release a programmed dosage on a 24 hours basis. The physician can adjust the dosage via computer. The pump reservoir will be refilled every few months and the battery will be good for about five years.
 
After the pump is placed, it is often recommended to start physical therapy and monitor for spasms. The overall goal of this dual treatment is reducing spasms and pain, and improving mobility and function.
 
In Conclusion
           
While it is likely that you will be among the 80 percent of people with MS that experience some degree of spasticity, treatment options are available that will reduce pain and increase function.