Spasticity, described as involuntary muscle stiffness, is one of several symptoms grouped together under the title of upper motor neuron syndrome. Often people with spasticity also have spasms and muscle weakness. They describe their affected limbs or trunk as staiff or difficult to move and associated with a “pulling” or “tugging” sensation that can be painful.
The intensity of the symptoms varies from person-to-person, day-to-day, hour-to-hour and can impact on many daily activities. For instance it can affect physical activities such as walking, transferring (moving from a seated to standing position for example), sexual activity, washing, dressing and picking up objects. A person’s safety while sitting and lying can also be compromised due to spasms or persistent poor positioning. The ongoing presence of spasticity and spasms can be described as painful, annoying, exhausting or embarrassing and can have an emotional impact, for example on mood, self-image or motivation.
“My muscles feel stiff all of the time; any
movement feels like I am pushing through syrup.”
(Marion who has MS and spasticity)
However it is important to remember that spasticity is not always detrimental; some people are able to stand, transfer or walk on their lower limbs due to spasticity or extensor spasms. In addition, some individuals like to see and feel the movement that a pain-free spasm affords them.
Poorly managed spasticity can unfortunately result in muscle shortening and the development of tendon and soft tissue contractures, such as when a limb becomes fixed in one position.
Once present, contractures are often difficult to treat and can have major functional implications, particularly in maintaining a person’s skin integrity, personal hygiene and positioning.
Contractures and spasms can lead to the development of pressure sores, which in turn may increase the severity of spasms and spasticity.
Spasticity and its associated symptoms can occur in MS at any time and its management should reflect a person’s changing needs over time. Such variability in presentation and individual expectations makes managing spasticity a challenge. Management should aim to sustain the balance between maintaining function, while minimising the effect of weakness, pain and other symptoms.
What is the purpose of evaluating and
measuring spasticity?
Everyone’s experience of spasticity and spasms is unique. To appreciate the impact on each person’s lifestyle, healthcare professionals need to engage in a process of detailed evaluation or assessment. The information gained in the process also guides the appropriate and timely selection of different treatments.
What does evaluation involve?
The evaluation process involves two integrated phases: firstly, an appreciation of the person’s history, current coping strategies, expectations and future lifestyle plans; and secondly, a physical assessment of both active and passive movements, including the recording of outcome measures. These phases will continually evolve as the healthcare professional and person with spasticity work together.
Paying attention to terminology
Terminology between health professionals and individuals with spasticity should always be clarified to avoid confusion and misinterpretation of symptoms. For instance, a person may say their limbs feel “heavy”, but this statement could relate to either a weakness or stiffness and so will require further explanation.
| Specific spasticity measures
There is an abundance of literature on measurement scales relating to spasticity. These have recently been vigorously reviewed and fall into three domains: clinical, biomechanical and neurophysiological.
These reviews established that there is no one tool that adequately measures spasticity. In practice, a series of measures (Figure 1) is often required to reflect different aspects of spasticity.
The purpose of measurement
The aim of measuring spasticity is to compare a person’s degree of spasticity, spasms and pain over time or pre- and post-treatments such as stretching programmes or particular medications. In the case of intrathecal drug trials, measurements can guide the person with MS, their family and the healthcare team to appreciate the potential impact of proceeding
with an intrathecal treatment.
How does it feel to be measured?
When measuring, the healthcare professional concentrates on the degree they can move a person’s limbs and how it feels when they do so.
They ask the person to focus on their main problem and what would be the one thing that could improve their current lifestyle. Between the “measurers”, numerical scores are shared,using for example, the Ashworth Score (Figure 1); however, all too often this has little or nomeaning to the person with spasticity.
People can respond to the measurement process both positively and negatively. Positive statements may include: “It feels really good to be stretched like this as it hasn’t happened for years”. Conversely, individuals may ask, “Is it good or bad?” or “Have I passed the test – will I be able to get a baclofen pump now?” For some people, being measured can make them feel as if they are enduring a test or being judged. The process encourages them to focus on their level of disability, which can be emotional, challenging and, at times, distressing.
Healthcare professionals need to be alert as to how a person may be feeling and provide support through education, engagement and involvement to enhance the measuring process.
Evaluating and measuring spasticity in partnership?
Education involves explaining why measurement is required, how it will help the team assessment and what the person’s role is in it. Emphasis must be placed on the fact that it is not a test and there is no right or wrong.
How a person is actively engaged in the measurement process is important. For people with high levels of cognitive impairment this may require creativity and flexibility to engage with them when they are most able; for example, breaking the process down into small sections to ensure they do not become too fatigued. The close involvement of a family member, friend or caregiver may be helpful to provide a perspective on how the outcome may affect the person’s lifestyle and care routine at home. Their involvement requires sensitivity, as the measuring process can also impact on their perception of their family member’s disability.
Measurement tools that involve self-reporting, especially those using visual and verbal analogue scales, can help the person with MS or carer to engage and feel part of the process. It also helps the person to focus and be more specific about changes they feel in their bodies or in the impact of spasticity on their lifestyle.
In summary, effective ongoing management of spasticity requires careful evaluation and consideration. Using measurement tools that foster partnerships with the person, their family member or caregiver and the healthcare team can be particularly beneficial.
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