Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Multiple Sclerosis Centers of Excellence

Quick Links

Veterans Crisis Line Badge
My healthevet badge

Multiple Sclerosis and Spasticity

Rachael L. Palmieri, MS, RN-C/ANP
Albany, New York VA Medical Center

What is spasticity? 
What are the clinical signs and symptoms? 
What increases spasticity? 
Who should be screened for spasticity? 
How do you grade spasticity? 
How do you manage spasticity? 
Summary 

What is spasticity?

Spasticity is one of the more common symptoms of multiple sclerosis, affecting approximately 80 percent of patients. The word “spasticity” means stiffness. It is defined as a velocity-dependent increase in muscle tone, which is usually associated with hyperactive deep tendon reflexes. In MS, spasticity is usually the result of relaxation and contraction in opposition muscles at the same time, caused by upper motor neuron damage that disrupts the normal coordination of muscle movement. Therefore, muscles are held in a constant state of contraction, causing increased stiffness and tone that can lead to decreased range of motion of major joints. This constant state of contracting muscles can eventually, shorten the connective tissue around the joints causing contractures. The stiffness people experience can range from a minimal level of stiffness to an extreme level. The stiffness can also be very painful and often times, interferes with performing activities of daily living.
Return to Top

What are the clinical signs and symptoms?

Spasticity occurs most frequently in the antigravity or postural muscles, including the muscles of the calf (gastrocnemius), thigh (quadriceps), buttock (gluteus maximus), groin (adductor), and occasionally the back (erector spinae). Clinical signs and symptoms of spasticity are variable and may include the following:

  • an increase in deep tendon reflexes;
  • clonus, a repetitive rhythmic beating movement of a foot or wrist;
  • difficulty initiating movements;
  • impaired voluntary movements;
  • difficulty relaxing muscles once a movement has ceased (needs to be distinguished from myotonia—however, myotonia is not linked to hyperactive or pathological reflexes and is not typically part of MS);
  • sensation of muscle tightening or pain;
  • flexion or extension synergy patterns;
  • decreased range of motion.

Return to Top

What increases spasticity?

Various factors increase spasticity. For some people, spasticity increases with fatigue, heat, humidity, infection, and sudden movements or position changes, especially lying in extension for long periods. Stimulation causes inappropriate activation of the muscle group, and infection, stress, and pain can worsen it. Spasticity can increase fatigue, as a result, of the excessive energy expenditures required to overcome tone during voluntary movement.
Return to Top

Who should be screened for spasticity?

Every MS patient should be screened for spasticity at every appointment. Screening involves assessing range of motion and functional ability, such as mobility, transfers, self-care, assistive devices, braces, strength, and balance. It is important to consider functional ability in addition to increased tone because some patients may require some tone increase to maintain posture, ambulation, and overall functional ability. eliminating spasticity is not always a goal, as some individuals with muscle weakness use their increased tone to stand and transfer.
Return to Top

How do you grade spasticity?

The Modified Ashworth Scale is used to grade spasticity. This scale measures the presence of velocity dependent resistance from 0 to 4, with “0” representing normal muscle
tone and “4” representing a limb that is fixed in flexion or extension.

MODIFIED ASHWORTH SCALE

 

Grade Description


0

No increase in muscle tone

1

Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension

1+

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM

2

More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3

Considerable increase in muscle tone passive movement difficult

4

Affected part(s) rigid in flexion or extension

Return to Top

How do you manage spasticity?

Management of spasticity involves five key strategies, not just pharmacologic options.

  1. Treat problems that increase the spasticity. Evaluate for infections, fatigue, stress, and pain and address those that are modifiable. Develop a specific exercise program for patients. Referral to physiatrists and physical and occupational therapists not only can benefit spasticity management but also can address conserving energy that will lessen fatigue.
  2. Develop a specific program for stiffness. The most effective and simplest way to reduce spasticity is passive stretching. This is accomplished by stretching the affected joint slowly and moving it into a position that stretches the spastic muscles. After each muscle reaches its stretched position, it is held there for approximately one minute to allow it to slowly relax and release the undesired tension. This stretching program should begin at the ankle to stretch the calf muscle and then proceed upward to the muscles in the back of the thigh, the buttocks, the groin, and, after turning from the back to the stomach, the muscles in the front of the thigh. Although range of motion is important, holding the stretch is very important and patience is essential when doing the stretches. Exercising in a pool may also be extremely beneficial because the buoyancy of the water allows body movements with less energy expenditure and more efficient use of many muscles. The optimal pool temperature should be 85 degrees. Warmer temperatures will produce muscle fatigue and colder temperatures can actually cause spasticity.
  3. Use specific mechanical devices. These should be use to counteract spasticity and prevent contractures. Specific devices, such as finger or toe spreaders, are used to relax tightness in the feet and hands and aid immobility. Orthoses for the wrist, foot, and hand are used to maintain a natural position and to prevent limitations on movement and the development of spasticity.
  4. Use pharmacologic approaches. Baclofen is the most commonly used antispasmodic medication used in MS treatment. While a common medication, dosing is very patient-specific due to the narrow therapeutic window between effectiveness and inability to maintain functional ability. Tizandine is effective in decreasing stiffness and muscle spasms with less effect on strength than many other drugs. Because it can cause drowsiness, it is especially useful for nighttime stiffness and spasticity and can be used with baclofen for greater effectiveness. Dantrolene is a direct-acting muscle relaxant; however, it also has a narrow window between effectiveness and weakness, much like baclofen. Diazepam is often useful for spasms that occur at night. Because of its sedative effect, it also helps to induce sleep, but, as a barbiturate, it also has addictive potential, which may make it inappropriate for some patients. Clonazepam also can be used to promote significant relaxation but must be used with caution for the same reasons as diazepam. Cyproheptadine is an antihistamine that has antispasmodic properties and can be a good add-on. It can cause sedation, but at a dose of 4mgdaily, it is useful for MS patients. Cyclobenzaprine is commonly used for back spasms. This drug can relieve limb spasms and works well in combination with other antispasmodics. Gabapentin is approved for seizures but also has antispasmodic properties. When taken in doses of more than 1gper day, it can ease problematic spasms. It can also be effective for pain caused by spasticity.
  5. Use surgical interventions like a motor point block or a baclofen pump when necessary. Patients with MS that have intractable spasticity and do not respond to oral medication, surgical intervention may be necessary. A motor point block, done by injecting phenol into specific groups of muscles, is useful for severe spasms that do not respond to drug therapy. This older surgical procedure may produce flaccidity in muscles. However, does not usually increase functional mobility and is not commonly used because newer techniques are available. At present, Botulinum toxin is more commonly used to cause a temporary blockade of neuromuscular transmission. It is practical for treating small group muscle spasms, especially the muscles of the eye or face, but can also be useful for larger muscle groups depending on the dosage necessary to control spasticity.

A more invasive approach to controlling spasticity is the use of a baclofen pump that delivers baclofen directly into the spinal canal. Programming can require sometime, but this method is very effective for severe spasticity. This procedure requires test dosing before actual pump implantation. Finally, there are several more invasive, nonreversible procedures, such as tenotomy, neurectomy, and rhizotomy, which can be considered. In some circumstances, these may be effective strategies.
Return to Top

Summary

Spasticity is a common symptom experienced by approximately 80% of people with multiple sclerosis. Muscle stiffness and spasms can interfere with daily activities and oftentimes this stiffness causes pain. Depending on the level of spasticity and pain, health care providers will prescribe various medications and recommend stretching strategies that will reduce spasticity. The goal of spasticity management is to develop strategies that increase functional ability and muscle tone that will aid in activities of daily living. For more information about spasticity management, contact your health care provider.
Return to Top

Date posted: March 2004
Last updated: September 2009