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Spasticity: Take Control

Cinda Hugos, MS, PT
Portland VA Medical Center, Oregon

The article is reprinted with permission from Paraplegia News (PN),  December 2010, Volume 64, Number 14, Pages 40-41.

What is spasticity?
Treatment Guidelines
Managing Spasticity
VA Resources
More Resources

What is spasticity?
Spasticity is a common symptom of multiple sclerosis (MS). It often begins as a feeling of stiffness or muscle tightness, especially after a period of prolonged inactivity such as a long-distance car ride or upon awakening in the morning. As a person moves around a little bit, the feeling often goes away. Eventually, though, if the stiffness is spasticity, it will likely gradually worsen until the stiffness is present most of the time.

Spasticity is caused by changes in the brain or spinal cord that result from the disease process in MS. Other neurological conditions that affect the brain or spinal cord also result in spasticity, such as stroke, spinal cord injury (SCI), traumatic brain injury or congenital conditions like cerebral palsy. These changes result in the muscles losing the smooth rhythm of normal movement that results from muscles turning on when needed and off when not needed. For example, when you bend your knee, the muscles that straighten the knee relax to allow the leg to bend easily and smoothly. And vice-versa  when you straighten your knee, the muscles that bend the knee relax and allow the knee to be straightened.

When spasticity gets worse, it can be associated with muscle spasms, or a bouncing or jumping in the muscles, called clonus. Muscle spasms may occur for no apparent reason or they may be a response to something touching a leg, for instance. Clonus is the involuntary repetitive bouncing usually most noticeable at the ankle when only the ball of the foot is on the floor. Clonus may be stopped by sliding the foot out slightly so the heel is also in contact with the floor and, if needed, by applying firm, steady pressure onto the bent knee to help get the heel to the floor.
Spasticity can be uncomfortable, even painful, and can interfere with walking, sexuality, and self-image. Severe spasticity can cause joint contractures and deformities if left untreated.
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Treatment Guidelines
Several years ago, the Paralyzed Veterans of America (PVA) sponsored the development of a treatment guideline on the management of MS spasticity. The information in the document was available primarily to health care professionals. But, the document contained valuable information that people with MS could use for spasticity management.

Based on the success of a previous guideline on fatigue in MS and a DVD-based group program that Lois Copperman PhD, OTR and I created in cooperation with the National MS Society, we decided to create a short DVD program of the highlights of the spasticity guideline. The resulting DVD, targeted to people with MS, their families, and health care providers, is “MS Spasticity: Take Control.”  This program was made possible by the PVA and an unrestricted educational grant from Medtronic to the PVA Education Foundation.

The program was made in cooperation with Oregon Health & Science University, the VA MS Centers of Excellence – West (VAMSCoE-West) and the Consortium of MS Centers (CMSC). It is available from the PVA, the VAMSCoE-West, the CMSC, and Medtronic.
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Managing Spasticity
“MS Spasticity: Take Control” features people with MS telling their personal and poignant stories about strategies they have used to manage spasticity and minimize its interference in their daily lives. As the DVD explains, the first step in managing spasticity is daily stretching of affected muscles.
Muscles and tendons start to lose motion at the ends of the ranges of motion first. Making sure to take each affected muscle through its full range of motion regularly is important to manage the spasticity as well as the tendency to develop deformities or contractures – permanent shortening of the tissues. For mild spasticity, stretching may be all that is needed.

Cinda Hugos helping a patient with spasticity to stretch 

For worse spasticity there are oral medications that are readily available and widely used. The most common medication is baclofen; the second most common medication is tizanidine. Generally these medications are well-tolerated and provide good control of spasticity. Stretching, however, must still be done to keep full range of motion when medications are used.

For people who do not tolerate the oral medications, a surgical procedure allows delivery of baclofen into the spinal canal near the spinal cord. This is called intrathecal baclofen delivery (ITB) via a pump. The programmable pump allows a constant flow of the medication for more consistent and even management of the spasticity. The medication amount can be changed according to a person’s needs throughout the day.

For instance, more baclofen may be needed at night to help control spasms that cause awakening, and less may be needed during the day when you are active and moving around. Again, stretching still needs to be done with the baclofen pump.

The U.S. Food and Drug Administration (FDA) recently approved using Botox (onabotulinum toxin A) to help control severe spasms in adults’ elbows, wrists, and fingers. In addition, many things can be changed in daily routines and environments to help keep spasticity from interfering. For example, if spasticity makes walking long distances difficult, a scooter may keep you moving. Systems to transport scooters are available that attach to many different types of vehicles.

Often people find that doing a combination of things – stretching, changing behaviors or routines, taking medications for spasticity or getting the ITB, and possibly using Botox - gives them the best spasticity management.
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VA Resources
Physical and occupational therapists familiar with MS and spasticity can help identify the correct stretches and how to change activities to keep individuals as active and involved at home, at work and in the community as they would like to be. The Department of Veterans (VA) has a wonderful system of health care providers that are available to veterans, and most Vets have access to physical and occupational therapists.
Neurologists or family doctors can initiate the necessary steps to seeing therapists that can help people live fully and meaningfully with MS.

More Resources
The MS Spasticity: Take Control DVD is available on the International Organization of MS Rehabilitation Therapists website  http://iomsrt.mscare.org/ 

For more information about other programs, services, and opportunities for Veterans go to Paralyzed Veterans of America http://www.pva.org/
 
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Date Posted: January 2011