Spasticity

Spasticity is measured by the degree of passive resistance to the stretch of muscles around joints, using the Ashworth or modified Ashworth scales. Usually carried out by a Chartered Physiotherapist. Treatment of spasticity involves both medications and physical approaches. Over-treating spasticity can impede mobility.

Two mainstays of treatment are baclofen (Lioresal®) and tizanidine (Zanaflex®, Tizaflex®). The major side effect of both drugs is sedation, which can be partially minimised by starting with a small dose and increasing slowly over time.

Second line therapeutic choices include benzodiazepines (such as Valium®), gabapentin (Neurontin®), and dantrolene (Dantrium®). Drowsiness is seen as a limiting factor for this group. Dantrolene has a more extensive side effect profile, including nausea, diarrhoea, incoordination, and possible liver toxicity. For people with severe spasticity resistant to oral medications, a few more aggressive approaches can be considered.

For focal spasticity, Botox® can be effective but must be targeted to specific muscle groups and repeat injections are required every 3-4 months. It can take 10-14 days to take full effect and needs to be combined with a stretching program and physiotherapy to be optimally effective.

Intrathecal Baclofen, administered through a baclofen pump, can produce dramatic improvement for more generalised spasticity in lower or upper limbs. The programmable pump is implanted in the abdomen and delivers a liquid form of baclofen directly to where it is needed—in the spinal canal. This route of delivery avoids the sedative effects of oral baclofen and allows small doses to be used. These pumps can be adjusted to deliver the appropriate amount of medication at the optimal time of day. Regular refilling of the pump, usually by the pain management team, is needed.

Candidates for the pump are initially assessed prior to implantation with a small test dose of baclofen. A positive response to the test dose gives confirmation that the implanted pump and catheter will be effective. The dose of baclofen is titrated up over the months after implantation to achieve an optimal effect. Potential complications may include catheter or pump failure that can lead to baclofen withdrawal syndrome due to the sudden decrease of the medication, and infection.

Factors that can precipitate spasticity include changes in position, elevated body temperature, painful stimuli, bladder or bowel distension, and infections. Spasticity can either be localised to the muscles of one extremity, or be more generalised in nature.

Maintenance of range of motion is the key to preserving functional ability and should be initiated as early as possible for those joints at risk for restriction from full movement. Daily stretching can be very helpful.

Each joint should be slowly moved to its full range of motion. Proper positioning techniques in the bed and chair are also important. If a person is able to walk or stand, this is helpful. Any home exercise program that focuses on the muscle groups of the hip, knee, and foot can be beneficial.

Cooling therapies can be helpful in warmer climates, including cooling garments and locally applied cool packs/towels. Orthotics such as splints and braces can help by maintaining good positioning. Monitor things like ingrown toenails, tight-fitting orthotics, and bladder/bowel functioning.

Consult with a physiotherpist or occupational therapist to determine what regimen would work best in your situation. If a muscle spasm does occur, the activity should be stopped until the spasm passes before proceeding. Encourage your loved one to move slowly and smoothly. Quick jerks and sudden moving can often set off a spasm.

There is some evidence to suggest oral cannabinoids may be effective in relieving spasticity in people with MS. Sativex, a cannabinoid-based treatment, received  a license in Ireland in 2014 but is not currently available as the HSE do not reimburse it. Some people with MS purchase CBD oil, which does not contain THC (the psychoactive component of cannabis) and as such is not illegal in Ireland. It should be noted, however, that such products are not properly standardised or regulated. Always consult with a medical professional before considering embarking on such a treatment.

When spasticity is unresponsive to medications or physiotherapy, phenol nerve blocks are a possibility where phenol is injected into a nerve in large muscle groups, mainly in the thighs.

Surgical techniques may also offer improvement in symptoms and prevent contractures. These include tendon releases, dissection or cutting of peripheral nerves, and surgical severance of spinal cord roots.  

When spasticity is unresponsive to medications or physiotherapy, phenol nerve blocks are a possibility where phenol is injected into a nerve in large muscle groups, mainly in the thighs.

Surgical techniques may also offer improvement in symptoms and prevent contractures. These include tendon releases, dissection or cutting of peripheral nerves, and surgical severance of spinal cord roots.