SPASTICITY

Spasticity is generally a component of spastic paresis and is defined as a velocity-dependent increased resistance of muscle to stretch due to activation of tonic stretch reflexes (3). Patients with MS most often experience spinal spasticity, in which the limbs are flexed and adducted and exaggerated responses to cutaneous stimulation are present (4). Spasticity occurs most frequently in the muscles that are responsible for maintaining upright posture. In the lower limbs, the muscle groups most likely to develop spasticity and be at risk for contractures are the iliopsoas, the quadriceps, the hamstrings, and the gastrocnemius (2). A small amount of spasticity does not have a significant effect on function, but when it becomes more prominent it can hamper gait, seating, and comfort. Spasticity may become extremely painful.

Spasticity is not always a disadvantage; stiff muscles can provide support for the patient's body against gravity when walking, thus permitting greater mobility. However, rapid or highly coordinated movements are no longer possible because the individual can no longer modulate muscle activity to suit momentary changes in the environment (4).

Increased stiffness in the muscles may mean that a great amount of energy is required to perform everyday activities. Reducing spasticity can produce greater freedom of movement and strength, frequently accompanied by less fatigue and increased coordination. Optimal management must include classic rehabilitation techniques to maximize the use of existing function and to prevent secondary manifestations such as clonus. The major means to reduce spasticity include stretching, range of motion exercise, and a variety of medications. When spasticity is severe, surgery may be necessary.

Painful flexor spasms and increased muscle tone are also an aspect of impaired motor control; they may be produced by any increase in noci-ceptive input, including urinary tract infection, constipation, pressure sores, ingrown toenails, or broken bones, or by some antidepressants and interferon beta-lb (4). Attention to such factors may significantly reduce spasticity.

The simplest way to reduce spasticity is passive stretching, in which each affected joint is slowly moved into a position that stretches the spastic muscles. Once the muscles reach their stretched position, they are held there for approximately 1 minute to allow slow relaxation and release undesired tension. This stretching program begins at the ankle to stretch the calf muscles, then proceeds to the muscles in the back of the thigh, the buttocks, the groin, and, after turning from back to stomach, the muscles on the front of the thigh. Spending some time each day in the prone position may relax the shoulder muscles, which otherwise predispose to flexion.

Attention to range of motion is key to maintaining mobility and skin integrity (2). Range of motion exercises differ from stretching exercises in that the movement about the joint is not held for any specific length of time. Both passive stretching and range of motion exercises are commonly taught by a physical therapist who is experienced with MS.

Exercising in a pool or spa may also be beneficial because the buoyancy of water allows movements to be performed with less energy expenditure, facilitating both stretching and range of motion exercises. These exercises consist of easy, slow, rhythmic, and flowing calisthenics that allow most of the joints to move through their full stretching range. The water temperature should be cool to lukewarm, approximately 80-84°; warmer temperatures should be avoided because significant fatigue may result.

Spasticity may also be reduced by relaxation techniques that involve a combination of progressive tensing and relaxing of individual muscles, accompanied by deep breathing techniques and imagery.

Mechanical Aids

Specific devices can counteract spasticity and prevent contractures. For example, a "toe spreader" or "finger spreader" can be used to relax tightness in the feet and hands and to aid mobility. Orthoses for the wrist, foot, and hand can be made to maintain a natural position and prevent limitations on movement and deformities. For example, an ankle-foot orthosis can be made to place the foot at many different angles to the ankle. A good orthotist can make the brace to take stress off the knee. Hinges in the material can add to its flexibility. All orthoses should be customized to allow for maximal benefit.

Medications

Baclofen (Lioresal®) is the most common antispasticity drug used in MS, and most patients respond well to it. The dose must be carefully determined for each individual; too little will be ineffective, whereas too much produces fatigue and a feeling of weakness. The correct dose is usually determined by starting at a low level and slowly increasing the amount until a maximum beneficial effect is achieved. The most common error when taking baclofen is to give up on it before it has reached the dose necessary to obtain proper relaxation. That dose may be as low as 5 mg per day, but as much as 40 mg four times a day may be necessary.

Tizanidine (Zanaflex®) has effects on spasticity that are similar to those of baclofen. It produces greater sedation than baclofen but less weakness, and may therefore be a useful medication for those in whom sedation is less of a concern than weakness. It may also be used in combination with baclofen, particularly as a nighttime dose when sedation may be a positive feature. The dose should be kept to the minimum needed for benefit in order to minimize sedation (4).

Another drug that sometimes is helpful in relieving spasticity is sodium dantrolene (Dantrium®), which acts directly on the muscle. It can be helpful, but it may induce weakness-even at low doses-and may cause liver toxicity. Spasticity may also be reduced by diazepam (Valium®), which is most often used at night because its calming effect also helps to induce sleep. Its strong sedative effect limits its use during the daytime.

Clonazepam (Klonopin®) is closely related to diazepam. Its main use has been to treat certain types of epilepsy. It produces significant relaxation and thus may be used as an antispasticity medication. Like diazepam, it sedates and is therefore best used at night. When using diazepam or Clonazepam, both the physician and the person with MS must keep in mind the potential for chemical dependency. Lorazepam (Ativan®) is also effective.

Another drug commonly used for back spasms is cyclobenzaprine hydrochloride (Flexeril®), which acts quite specifically on such spasms, but may settle limb spasms as well. It usually works best in combination with another spasticity medication, but it is very sedating in many patients. Any of these drugs may become less effective when taken for a prolonged period, requiring cessation for a period of time, after which they may again become effective. Some data suggest that gabapentin (Neurontin®) may reduce spasticity in doses of 300-900 mg every 8 hours.

People with MS occasionally develop "paroxysmal" or "tonic" spasms, in which a limb may assume the flexor or extensor position. Carba-mazepine (Tegretol®) generally controls such spasms, although baclofen may also be effective. Cortisone may decrease spasticity in general and is effective for paroxysmal spasms when used on a short-term basis; its long-term use is not advocated because of numerous risks.

Another approach to the management of severe spasticity involves the use of a pump to deliver baclofen intrathecally. A tube is placed in the spinal canal and connected underneath the skin to the pump in the abdominal region, through which the drug is delivered intrathecally. The newest pumps can be programmed by computer via radio waves so that the dose can be changed as needed. For some patients, this technique may provide relief of intractable spasticity. Because the required doses of baclofen are so low (micrograms), side effects are also low and there is almost always a significant decrease in fatigue and malaise. This technique may be especially useful with nonambulatory patients; severe spasticity may be transformed into flaccid paresis, which makes daily function and nursing care much easier. This treatment is aggressive and expensive. It should be reserved for those with severe spasticity that cannot be adequately managed by oral medications.

Surgical Management

Spasms occasionally become so severe that no medication is effective. When this occurs, a phenol motor point block may be indicated. This produces decreased tone in the muscles, which may be more comfortable but usually does not increase functional mobility.

Local injections of botulinum toxin (Botox®), which blocks release of acetylcholine from motor nerve endings, are effective in weakening any muscle for approximately 3 months (5). Botulinum toxin causes a temporary blockage within the muscle; it is somewhat easier to control than phenol but may need more repetitive injections. This treatment is practical for small muscle spasms, especially around the eye or face. Severe spasms may be managed by surgical procedures that involve cutting nerves or tendons to decrease the contraction of specific muscles that are producing serious stiffness.

The faithful use of an exercise program and the appropriate use of drugs when needed significantly increase the level of function and avoid the development of these more severe problems.

TREMOR

Tremor is one of the most frustrating symptoms to treat in MS and can be a major cause of diminished function. There are many different kinds of tremors; some have gross oscillations, others are fine; some occur at rest, others occur only with purposeful movement; some are fast, others are slow; some affect the limbs, others may involve the head, trunk, or speech; some are disabling, others are merely a nuisance; and some are treatable, others are not. As with all symptoms, because of this wide variation, prop er diagnosis is essential before correct management decisions can be made.

Pharmacologic Management

The most common tremor seen in MS - and the most difficult to treat - occurs as the result of demyelination in the cerebellum and its pathways, which often results in a gross tremor that is relatively slow and occurs with purposeful movement of the arm or leg. This type of tremor is almost always exaggerated during times of stress and anxiety, so one mode of managing the problem is treatment with drugs that have a calming or sedative effect.

Hydroxyzine (Atarax® and Vistaril®) is an andhistamine that may settle a minor tremor that has been magnified by stress. Clonazepam (Klonopin®) may also decrease a tremor via its sedative effect. The antitremor effect must be balanced against the generally unwanted effects of sedation by carefully monitoring the dose until the desired effect is achieved. Propranolol (Inderal®) and INH (isoniazid) have been used historically to treat tremor but with disappointing results. The long-acting preparations of propranolol have a smoother and more salutary effect (eg, propranolol LA 60 mg one or more times a day).

Some studies have shown that low doses (50-200 mg three times a day) of the anticonvulsant primidone (Mysoline®) may alleviate this difficult symptom, although it is sedating. Low doses may be worthwhile. Acetazo-lamide (Diamox®) is a diuretic that has some antitremor properties and may be of value in selected patients.

Because a component of spasm is often involved in gross tremors, baclofen may provide some relief. The potential but reversible side effect of weakness must be balanced against the tremor-reducing effect of the drug, again by careful adjustment of the dose.

Recent studies indicate a reasonable response to the anti-anxiety drug buspirone (Buspar®), which is nonsedating and nonaddictive.

Other Treatments for the Management of Tremor

Drugs are not the complete solution to the management of tremor. Physical techniques provide another approach. Physical treatments fall into three general categories:

Patterning is a controversial technique that is used by physical and occupational therapists to trace and repeat basic movement patterns. It is based on the theory that certain muscles can be trained to move in a coordinated fashion by repeatedly using the nervous circuit involved in a movement. These normal movements are guided and assisted by the therapist until they become automatic. Minor resistance is then added and removed while the patient repeats the patterns independently. The muscles gradually appear to develop increased endurance for these learned movements and manage to retain control when the patterns are applied to functional tasks.

Immobilization is the placement of a rigid brace across a joint, fixing it in one position and dampening the severity of a tremor by reducing random movement in the joint. Bracing is most helpful in the ankle and foot, providing a stable base for standing and walking. It may also be used for the arm and hand. The desired position of function is defined by the tasks that are to be facilitated, such as writing, eating, or knitting; the brace is used to immobilize the arm or hand for these tasks and then removed. Lightweight high-top shoes with leather soles may be helpful.

Weighting involves the addition of weight to a part of the body to provide increased control over its movements. The underlying theory behind this approach is that more muscles will be used to stabilize a distant point in the body (hands, wrists, feet, ankles) when a heavier object is involved. This stabilizing action tends to reduce tremor and provide greater sensory feedback to the brain. In practical terms, either the limb itself may be weighted or the object being used may be made heavier, including utensils, pens and pencils, canes, or walkers.

These techniques are used primarily for tremors that affect the limbs. Their goal is to teach the person with MS to compensate for tremor by providing as much stability for the limbs as possible. It may be important to develop postural adjustments, such as using one's arms close to the body. Adaptive equipment and/or assistive devices that are nonskid, easy to grasp, and stable are helpful and can be used for many activities.

Tremors of the head, neck, and upper torso are more difficult to manage than those of the limbs. Stabilizing the neck with a brace may be helpful. Stereotactic surgery has occasionally been used to control cerebellar tremor, but results are mixed and this procedure is generally used only as a last resort (6). Deep brain stimulation and thalamic stimulation are currently being explored as possible means to reduce MS tremor.

Tremors of the lips, tongue, or jaw may affect speech by interfering either with breath control for phrasing and loudness or with the ability to form and pronounce sounds. Speech therapy may involve changing the rate of speaking or the phrasing of sentences. Suggestions may be made as to the placement of the lips, tongue, or jaw for the best possible sound production. A simple pace board-a pattern of rectangles set next to each other-may slow the person down and allow for improved understanding. The person points to each square while uttering a single syllable. If he or she can slow down to keep pace with the pointing, a dramatic increase in clarity of speech often results. Pace boards can be simple and effective at virtually no cost. In some instances, tremor may make it impossible to speak, in which case alternative communication devices must be used.

Oscillating movements of the eyes (oscillopsia) are a severe source of disability for some patients. Large does of gabapentin (Neurontin81) may be helpful. Adjusting head position to reduce tremor is also helpful. Covering one eye with an opaque lens may also reduce symptoms.
None of these techniques completely eliminates the problem of tremor. The goal is continued function, which can often be achieved by combining some of these therapies.

BALANCE AND COORDINATION

Vertigo, imbalance, and incoordination are frequent problems in MS. They put individuals at risk for falls and injury, which complicates management and increases disability. A fall with a fracture is a common event that will move a patient from being ambulatory with a cane or a walker to permanent wheelchair status (6).

Control of balance is complex and involves essentially every part of the nervous system. For this reason, lesions in a number of areas may affect the MS patient's balance and coordination. These include the visual system, proprioceptive system, vestibular system, and sensorimotor system. Cerebellar incoordination and tremor are among the most difficult MS symptoms to treat and often are incapacitating (6).

An aid to enhance ambulatory mobility becomes essential if balance or coordination is a problem. Whether a cane, crutch, or walker is used, it is necessary that it be correctly sized and properly used. This is best accomplished by a skilled physical therapist. The advent of new large-wheel walkers with hand controls, a seat, and a basket has been a significant innovation for many patients.

WEAKNESS

Weakness is experienced by at least half of all people who have MS. Ambulatory patients who walk a short distance may begin with no symptoms of weakness, only to develop a limp and progressive weakness so that walking becomes impossible. In some instances, weakness is a symptom of a developing exacerbation; when this occurs, weakness is the symptom least likely to recover completely (7).

It is vital that the source of weakness be understood in order to properly manage it; if it is due to deconditioning, weakness may be improved by lifting weights (progressive resistive exercise). Specifically, progressive resistive exercises targeting the disused muscles may be helpful. However, when weakness is due to poor nerve conduction in the spinal cord and the brain, excessive exercise may add to the fatigue.
Physical therapy is integral to the management of weakness in MS. To enhance function, the physical therapist attempts to substitute the use of uninvolved muscles for those whose function is impaired. As noted by Brar and Wangaard (8), frequently used techniques include:

• active assistive exercise and active exercises


• proprioceptive neuromuscular facilitation (PNF) technique


• therapeutic exercises


• resistive exercises

AMBULATION

Mobility impairment is frequently associated with MS. Approximately 65 percent of patients are able to walk 25 years after diagnosis (9); how well and frequently they walk-and how well they are able to function in the community-is closely linked to careful management of the symptoms discussed in the preceding section.

If ambulation becomes impaired, a more practical means to accomplish this goal should be substituted. Emotional consequences must be addressed because people value being ambulatory far beyond its true value.
"Foot drop" is manifested when the toes of the affected foot touch the ground before the heel, disrupting balance and causing falls. A polypropylene insert used inside the shoe to keep the foot from dropping is very effective. This lightweight ankle-foot orthosis-or AFO- picks up the foot and allows it to follow through in the normal heel-foot manner. Ankle-foot orthoses can also be designed to decrease spasticity by tilting the foot to a specified angle and keeping it from inverting or everting. The proper use of an AFO decreases fatigue while increasing stability.

If the hip muscles are also weak, the leg will swing out in front to allow the foot to clear the ground. In order to maintain stability, the knee is often forced into hyperextension, which puts significant stress on the knee. After a period of time, the knee begins to hurt and may become swollen secondary to arthritis. To prevent this condition, a metal device called a Swedish hyperextension cage can prevent the knee from snapping back. Alternatively, a custom-made knee brace may be necessary. If balance is also a problem, an assistive device such as a cane may be needed. Two canes may be needed if weakness is pronounced in both legs. If balance and weakness are more severe, it may be necessary to use forearm Lofstrand crutches. These crutches provide greater stability than a cane, and their use does not require as much strength in the upper extremities. Walkers are important aids, and the newer style large-wheel walkers with hand controls, a basket, and a seat are a boon for many patients.

If walking is still difficult or impossible, a wheelchair may be the correct choice. Ultra-lightweight wheelchairs are often helpful in patients with well-preserved arm strength, but they may add to fatigue. A three-wheeled motorized scooter can be a boon for people with MS because it does not carry the stigma associated with a standard wheelchair. A motorized scooter is best used by those who have retained some means of walking because the seating system is not designed for all-day sitting. Adequate sitting balance and the use of the upper extremities are also essential.

Those who do not possess the skills necessary to use a three-wheeler appropriately may achieve independence using a lightweight motorized wheelchair. A standard manual wheelchair often does not offer sufficient independence because of the fatigue generated by operating the chair and the coordination necessary to control it. The key in choosing a chair or scooter is independence. The proper device should be selected to regain control and independence in the environment. Help from a physical therapist or a physiatrist is necessary to select the most appropriate mobility device.

PREVENTING IMMOBILITY

People with MS are too often told to rest and not overdo, and the fear of fatigue becomes almost unbearable. There is no real basis for this fear. People with MS are not fragile! Proper exercise leads to increased fitness and less fatigue.

The process is slow, and it begins with a carefully developed exercise prescription. Like medicine, exercise should be prescribed by a professional-usually a physical therapist or a physician-who knows how to tailor the exercises to the individual. The exercise prescription should have four elements:

• The type of exercise (aerobic, strengthening, balance, stretching)


• The duration of exercise (how long to exercise)


• The frequency of exercise (how often to exercise)


• The intensity of exercise (how hard to exercise)

UPPER EXTREMITY FUNCTION

The same medications used for control of lower extremity tone are used when dealing with the arms, with the rehabilitative emphasis on the shoulder. It is extremely important to prevent development of a contracture. Multiple sclerosis may result in contraction of the hands, and the use of bracing becomes important. Once again, keeping the joints mobile is essential. Stretching the digits out at night to prevent flexion contractures is necessary. Using a rubber ball is a bad idea.

Occupational therapists (OTRs) are most generally involved in managing upper extremity dysfunction and the activities of daily living (ADLs). Treatment may involve the use of static splints, mobile arm supports, and other devices that can compensate for upper extremity weakness (10).

No exercises are of real value in tremor management. As noted previously, there are medications that may help. Sometimes devices that mechanically hold the arms can be used for stabilization. Weights may be added to the arms to decrease gross oscillations. Adapted feeding devices may allow for eating independence.

Upper extremity problems are significant, but because the distance from the spinal cord to the legs is longer, lower extremity problems are more common. Nonetheless, the aggressive OTR should focus on devices to aid in writing, dressing, toileting, and other important activities. Technology has resulted in improved wheelchair adaptations along with "high tech" devices to help maximize what can be done with impaired arms and hands.

It is important that the general physician be aware of the services that can be provided by health care professionals that include OTRs, RPTs, RNs, and specialist physicians such as physiatrists. Whether the problem is spasticity management or eating, the interdisciplinary team will be invaluable partners. The concept that there is nothing to be done could not be farther from the truth. It is important to realize, however, that time and patience may be needed to obtain maximal effect.

References

1. Haselkorn JK, Leer SE, Hall JA, Pate DJ. Mobility in multiple sclerosis. In: Burks JS, Johnson KP-(eds.). Multiple sclerosis: Diagnosis, medical management, and rehabilitation. New York: Demos Medical Publishing, 2000 (In Press).


2. Lance JW. Symposium synopsis. In: Feldman RG, Young RR, Koella WP (eds.). Spasticity: Disordered motor control Chicago: Year Book, 1980:485-495.


3. Young RR. Spastic paresis in multiple sclerosis. In: Burks JS, Johnson KP (eds.). Multiple sclerosis: Diagnosis, medical management, and rehabilitation. New York: Demos Medical Publishing, 2000 (In Press).


4. Davis D, Jabbari B. Significant improvement of stiff-person syndrome after paraspinal injection of botulinum toxin A. MovDisord 1993; 8:371-371.


5. Herndon RM, Horak F. Vertigo, imbalance, and incoordination. In: Burks JS, Johnson KP (eds.). Multiple sclerosis: Diagnosis, medical management, and rehabilitation. New York: Demos Medical Publishing, 2000 (In Press).


6. Petajan JH. Weakness. In: Burks JS, Johnson KP (eds.). Multiple sclerosis: Diagnosis, medical management, and rehabilitation. New York: Demos Medical Publishing, 2000 (In Press).


7. Pal Brar S, Wangaard C. Physical therapy for patients with multiple sclerosis. In: Maloney FP, Burks JS, Ringel SP (eds.). Interdisciplinary rehabilitation of multiple sclerosis and neuromuscular disorders. Philadelphia: JB Lippincott, 1985:83-102.


8. Lechtenberg R. MS fact book. Philadelphia: FA Davis, 1988. 10. Wolf BG. Occupational therapy for patients with multiple sclerosis. In: Maloney FP, Burks JS, Ringel SP (eds.). Interdisciplinary rehabilitation of multiple sclerosis and neuromuscular disorders. Philadelphia: JB Lippincott, 1985:103-128.