Multiple Sclerosis Centers of Excellence
Spasticity: Take Control
Cinda Hugos, MS, PT -- Portland, OR
Spasticity is a common symptom of 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.
Treatment Guidelines and Research
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 healthcare professionals. But, the document contained valuable information that people with MS could use for spasticity management. In addition to the treatment guideline, the PVA Education Foundation supported development of a short DVD program of the highlights of the spasticity guideline. The resulting DVD, targeted to people with MS, their families, and healthcare providers, is “MS Spasticity: Take Control.”
The VA Rehabilitation Research & Development supported development of a stretching DVD to accompany the PVA educational DVD and a pilot study of effectiveness of the complete program. Based on this preliminary effectiveness, the VA has recently funded a larger study of the program that will be completed in 2022. If effective, this will be the first scientifically supported evidence for the benefit of stretching for spasticity.
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.
For worse spasticity, there are oral medications that are readily available and widely used. The most common medication is baclofen while 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 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.
Botulinum toxin injections, also with stretching, are used 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, getting intrathecal baclofen, and/or using botulinum injections - gives them the best spasticity management.
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 VA has a wonderful system of health care providers that are available to Veterans, and most Veterans have access to physical and occupational therapists. Neurologists or primary care doctors can initiate the necessary steps to seeing therapists that can help people live fully and meaningfully with MS.
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