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Spasticity - Randall T. Schapiro, M.D.
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Spasticity means stiffness. When demyelination occurs in the nerves that regulate muscle tone, the result often is stiffness or spasticity. Because there are many nerves in the brain and spinal cord that regulate movement, spasticity is a common problem in Multiple Sclerosis (MS). The stiffness often is minimal and not bothersome. In fact, a person sometimes needs the stiffness provided by spasticity to stand or pivot. At other times stiffness may become painful and may interfere with performance activities of daily living.
Spasticity tends to occur most frequently in a specific group of muscles that are responsible for maintaining upright posture.
The Management of Spasticity
- Treat problems that increase spasticity-infection, pain, skin breakdown
- Develop a thorough stretching programthat includes both active and passive stretching
- Use mechanical aids (orthoses) as needed
Medications
- Surgical management used for severe spasticity that does not respond to medication
These muscles are called antigravity or postural muscles. They include the muscles of the calf (gastrocnemius), thigh (quadriceps), buttock (gluteus maximus), groin (adductor), and occa-sionally the back (erector spinae).
When spasticity is present, the increased stiffness in the muscles means that a great deal of energy is required to perform daily activities. Reducing spasticity produces greater freedom of movement and strength, and frequently also lessens fatigue and increases coordination. The major ways in which spasticity is reduced include stretching exercises, physical therapy, and the use of medications. If spasticity does not respond to these measures and causes discomfort, a surgical procedure may be necessary.
The first management strategy is to alleviate associated problems that magnify spasticity. These include infection, pain, skin breakdown, and any similar process that may stimulate spasticity. |
Stretching
The second management strategy is to develop a specific exercise program for stiffness. An independent stretching program based on some of the principles used in physical therapy may be used at home. A thorough stretching program includes a series of exercises that are performed in certain sitting or lying positions that allow gravity to aid in stretching specific muscles.
While one is in the sitting position, a towel or long belt may be used to pull on the forefoot and ankle to stretch the calf, or to stretch the thigh muscles when one is lying on the stomach. Certain muscles may be relaxed more effectively while one is lying on the stomach or side or while lying on all fours over a beach ball, rocking rhythmically forward and backward.
The simplest and often most effective way to reduce spasticity is passive stretching, in which each affected joint is slowly moved into a position that stretches the spastic muscles. After each muscle reaches its stretched position, it is held there for approximately a minute to allow it to slowly relax and release the undesired tension. This stretching program begins at the ankle to stretch the calf muscle, then proceeds 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 on the front of the thigh.
Range of motion exercises differ from stretching exercises in that the movement about the joint is not held for any specific length of time. Although range of motion is important, holding the stretch is significant, and patience is essential when doing the stretches.
Exercising in a pool also may be extremely beneficial because the buoyancy of the water allows movements to be performed with less energy expenditure and more efficient use of many muscles. We recommend using the pool for both stretching and range of movement exercises. The pool temperature should be cool, about 85 degrees; this may feel cold to some people, but warmer temperatures should be avoided because they produce fatigue. Many people with MS have a limited range of movement in at least some joints and muscles, and the key to managing spasticity is to expand the number and kind of movements that can be performed. The exercises should be performed with a minimum of effort.
Spasticity also may be reduced by the use of relaxation techniques that involve a combination of progressive tensing and relaxing of individual muscles, accompanied by deep breathing techniques and imagery. |
Mechanical Aids
The key to managing spasticity in Multiple Sclerosis is to expand the number and kind of movements that can be performed, in which the range of movement possible for a given joint becomes restricted as the result of spasticity. For example, a "toe spreader" or "finger spreader" are used to relax tightness in the feet and hands and to aid in mobility. Braces for the wrist, foot, and hand are used to maintain a natural position and to prevent limitations on movement and deformities. These devices are called orthoses. An orthosis for the foot is an ankle-foot ortho-sis, or AFO. AFOs are made to place the foot at many different angles to the ankle. A good orthotist can make a brace to take stress off the knee. Hinges may increase flexibility. All orthoses should be customized to allow for maximal benefit. |
Medications
The third management strategy for spasticity is medical. Spasticity often is managed effectively by medications. Baclofen (Lioresal) acts on the nerves that control the spastic muscles at their site of origin in the spinal cord. It is the most common antispasticity medication used in Multiple Sclerosis, and most people 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 because it interferes with the proper degree of stiffness that is needed for balance and erect posture. The correct dose usually is determined by starting at a low level and slowly increasing the dose until a maximal beneficial effect is obtained. The most common mistake when taking baclofen is to give up on it too soon, so that the dose never reaches the level necessary to attain proper relaxation. That dose may be as low as one half of a pill (5 mg) per day, but some people may need to take as much as 40 mg four times a day.
Tizanidine (Zanaflex), a newer antispasticity medication, acts on a different area of the spinal cord than baclofen. It appears to be effective in decreasing stiffness and muscle spasm, with less effect on strength than many other drugs. It must be used carefully and slowly because sleepiness inevitably results if the dose is increased too rapidly. The starting dose is 2 to 4 mg up to a maximum of 36 mg per day. It is quite effective and may be combined with baclofen in problem situations. |
Medications for the Management of Spasticity Medication
| Baclofen (Lioresal) | May produce weakness at higher dose |
| Tizanidine (Zanaflex) | Often combined with baclofen; may produce drowsiness |
| Sodium dantrolene (Dantrium) | May produce weakness |
| Diazepam (Valium) | Highly sedating; most often used at night; may become addictive |
| Clonazepam (Klonopin) | Sedating; most often used at night |
| Cyproheptadine HC1 (Periactin) | Sedating; used primarily as an "add on" medication |
| Cyclobenzaprine HC1 (Flexeril) | Used for back spasms; most often combined with other medications |
| Gabapentin (Neurontin) | May ease spasms that are difficult to manage |
| L-dopa (Sinemet) | Especially useful for nighttime spasms |
| Selegiline (Eldepryl) | Especially useful for nighttime spasms |
| Carbamazepine (Tegretol) | Used for flexor spasms of the arm or leg |
| Cortisone | Effective for paroxysmal spasms; should only be used on short-term basis |
Another medication that sometimes is used for spasticity is sodium dantrolene (Dantrium), which acts directly on muscles. It is a very potent medication that needs to be used carefully. It may be helpful, but it also may induce weakness, even at low doses.
Spasticity also may be reduced by diazepam (Valium), which is most often used for the relief of spasms that occur at night. Its calming effect also helps to induce sleep. Its strong sedative effect limits its use during the daytime. Diazepam must be prescribed with caution because it may become addictive if it is used too frequently.
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 best used at bedtime.
When using diazepam or clonazepam, both the doctor and the person with Multiple Sclerosis must pay attention to the potential for chemical dependency. When properly used at appropriate doses, this is not a major problem. However, if the dose must be continually increased and the person is using the medication not for spasticity but as a crutch to escape the realities of the world, it should no longer be used.
Cyproheptadine (Periactin) is an antihistamine that has antispasticity properties and may be a good add-on medication at certain times. Its sedating effect limits its use, but doses of 4 mg taken when needed may be helpful.
Another drug that commonly is used for spasms in the muscles of the back is cyclobenzaprine HCl (Flexeril). It acts quite specifically on these spasms, but also may relieve limb spasms. It usually works best in combination with one of the other anti-spasticity medications. Gabapentin (Neurontin) is a newer medication that has been approved for use in seizures. This medication also has anti-spasticity properties, and when it is taken in doses of over 1 gm per day often eases problematic spasms.
L-dopa (Sinemet) is a Parkinson's disease medication that also decreases spasms, especially the painful spasms that tend to occur at night and may become especially prominent and painful. Selegiline (Eldepryl), another drug that originally was developed for use in Parkinson's disease, may have a similar effect.
Any of these medications may become less effective when they are taken for a prolonged period (this is referred to as the development of "tolerance"), and it may be necessary to stop taking them for a while, after which they may again become effective.
People with Multiple Sclerosis very occasionally develop "paroxysmal" or "tonic" spasms, in which an entire arm or leg may draw up or out in a stiff, clenched, or extended position. If such spasms involve both legs, they are termed extensor or flexor spasms. These spasms may be so strong that they literally propel a person out of his or her chair. Obviously, this is disconcerting, but it also is potentially dangerous. Carbamazepine (Tegretol), another drug used for seizures, generally is used to control such spasms, although Lioresal and Zanaflex also may be effective. Cortisone may decrease spasticity in general and is quite effective for paroxysmal spasms when it is used on a short-term basis. Its long-term use is not advocated because of numerous associated risks.
The management strategy with medication is to use what works at the proper dose. Overdosing may cause increased weakness, somnolence, and decreased function. |
Surgical Management
For those who have severe intractable spasticity, the kind that causes problems with all functions and is not responsive to exercise or medication, a spasticity-decreasing procedure may be necessary. Nerves that control specific muscles of the leg may be destroyed with phenol, a chemical that is injected into the muscle. This is called a motor point block. It is used only for the most severe spasms that do not respond to drug therapy. It may produce flaccidity in the muscles, a profound looseness that is the opposite of spasticity. This relaxation may be more comfortable, but it usually does not increase functional mobility. It becomes progressively more difficult to repeat this procedure because of technical problems.
A better, more modern technique, is the use of botulinum toxin (Botox), a poison made by bacteria. It is a paralytic agent that causes a temporary blockage of the nerve and muscle. It is easier to control than phenol, but it may require more repetitive injections into the muscle. It is practical for treating small muscle spasms, especially those about the eye or face, but severe large muscle spasms may require too high a dose to be safe. Severe spasms also may be managed by a surgical procedure that involves cutting nerves or tendons to decrease the contraction of specific muscles that are producing stiffness.
A better approach to the management of severe spasticity involves the use of a pump (Synchromed) that delivers baclofen directly into the spinal canal. A tube is placed in the canal and then connected (beneath the skin) to a pump implanted in the abdominal region. The pump contains baclofen, which is delivered into the spinal canal at prescribed levels. The pump may be programmed by computer via radio waves so that the dose may be changed as needed. For some patients, this technique may provide relief for intractable spasticity. Because the baclofen is delivered directly into the spinal canal and the level in blood and tissues remains low, side effects also are very low and there almost always is a significant decrease in fatigue and malaise. This treatment is aggressive and expensive and should be reserved for those who have severe spasticity that cannot be adequately managed by oral medications. |
Contractures
A contracture is a "freezing" of a joint so that it cannot bend through its full range of motion. This occurs when a joint has not been kept mobile, usually as the result of spasticity. A joint that develops a contracture becomes useless and often is painful.
All of the approaches used to treat spasticity play a role in the management of contractures. The joint must be slowly mobilized, sometimes using heat or ice applied just before stretching to ease pain and allow for more efficient stretching. Special equipment such as a tilt board may be helpful. Baclofen (taken either orally or via the pump), tizanidine, clonazepam, diazepam, or dantrolene may be used to decrease muscle tone and permit faster relief from the contracture. Occasionally, cortisone is injected directly into the joint to decrease inflammation and increase mobility. Braces may be designed to slowly stretch the joint; by changing the angle of the brace over time, a frozen joint sometimes may become mobile. Serially casting the joint (as if it were broken) by slowly stretching it with the casts may be helpful. In extreme conditions surgery may be required to release the muscle tendons to allow the joint to move.
Joints usually freeze into a contracted position, but they occasionally become fixed in the extended or straight position. Although this usually is less of a problem in terms of overall function, it is not considered an acceptable outcome, and this type of frozen joint generally is treated in a similarly aggressive manner as a contracted joint. |
Source:
Symptoms Management in Multiple Sclerosis, 3rd Edition, By: Randall T. Schapiro, M.D., 1999, New York: Demos, pp33-40. ISBN: 1 888 799 22 6
Reproduced with kind permission from Demos Medical Publishing
Available from Demos Medical Publishing, 386 Park Avenue South, Suite 201, New York, NY 10016, USA. Tel +(212) 683 0072. Fax: +(212) 683 0118. Web site: www.demosmedpub.com or by e-mail to orderdept@demospub.com |
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