SECTION 2: SPASTICITY
This common symptom of MS usually affects the muscles involved in walking and maintaining upright posture. With normal muscle function, opposite muscles work in opposite directions, meaning that one muscle pulls while the other relaxes. Spasticity is a condition that occurs when opposite muscles both contract or relax at the same time, causing an increase in muscle tone. This can often lead to muscle stiffness, muscle spasms, reduced joint mobility, and related discomfort. It also contributes to fatigue, because more energy is required to perform daily activities.
NON-PHARMACOLOGIC MANAGEMENT STRATEGIES
Manage Secondary Causes
Because spasticity may be worsened by a variety of other MS symptoms and non-MS-related conditions, it is important that spasticity be managed as part of a comprehensive strategy. Common MS symptoms that contribute to an increase in spasticity include fatigue, stress, heat, urinary tract and other infections, and pain. Therapies designed to relieve these symptoms may result in significant improvement in spasticity.
Stretching and Range of Motion Exercises
A physical therapist can develop a specific stretching and range of motion (ROM) exercise program for your specific issues. Aquatic exercise may also be helpful.
Orthotics and Walking Aids
Simple devices such as an ankle-foot orthosis (AFO) may help walking by relieving the effects of foot-drop and by reducing spasticity.
A variety of pharmacologic agents can be helpful in managing spasticity, some of which are used "off label." This means that they have been approved for use in other conditions, but have also been shown (for example) to be effective in spasticity management for individuals with MS, despite not being specifically approved by the FDA for this purpose. Optimal management is sometimes achieved by combining several medications, which has the benefit of reduced Side effects .
Baclofen (formerly available as Lioresal®)
This is an oral medication whose escalating dose is usually begun at 5 mg daily, with a typical effective dose of 30 to 90 mg daily; some individuals may require higher doses. Most doctors start with a low dose and increase it gradually. Discontinuation of the drug is also done by gradually lowering the dose to avoid seizures. This is the most commonly prescribed drug used to manage spasticity, and most people with MS respond well to it.
Side effects include drowsiness, dry mouth, and lightheadedness. Again, the drug should not be stopped abruptly, as seizures, hallucinations, and/or agitation may result.
Zanaflex® tablets and Zanaflex Capsules®(tizanidine hydrochloride)
This oral medication is available as tablets or capsules, however, these have slightly different formulations from each other and from the generic versions, so you should not switch without consulting your physician. The starting dose is usually 2 to 4 mg daily, gradually increased to a maximum of 36 mg daily. It is particularly useful for nighttime spasticity, and is often combined with baclofen.
This is a short-acting drug. Because it reaches maximum effectiveness in 1 to 2 hours, and lasts for a maximum of 6 hours, its dosing schedule needs to be carefully monitored. Clinical trials have demonstrated safety and efficacy. A preliminary study suggests that 12 mg tizanidine taken sublingually (under the tongue, for rapid absorption) just before bedtime, results in a statistically and clinically significant reduction in next-day spasticity (this type of administration has not yet been approved).
Side effects may include sedation, low blood pressure, weakness, constipation, and dry mouth.
This is an oral medication in tablet form, with initial doses of 2 to 5 mg that may be increased as needed. The sedative effects of diazepam and other anti-anxiety medications make it especially helpful for nighttime use; it is not recommended for daytime use because of its sedative properties.
Side effects include drowsiness, dizziness, lightheadedness, low blood pressure, and shortness of breath.
This is an oral medication in tablet form, whose usual dose is 0.5 to 1 mg. Clonazepam is chemically related to diazepam, and is used in MS to treat tremor and pain as well as spasticity. Because it is sedating, it is most commonly used at night.
Side effects include dizziness, lightheadedness, constipation or diarrhea, mouth dryness, and rapid heartbeat.
This is an oral medication with a usual dose of 10 to 20 mg. Dantrolene acts directly on muscles to relieve cramping, and may be helpful in some situations. However, its use is limited because it can induce weakness, even at low levels.
Side effects most commonly seen are weakness, unusual tiredness, drowsiness, nausea, diarrhea or constipation, sleep difficulties, and headache. Periodic blood tests to evaluate liver function are recommended.
This is an oral medication available in tablet form. The dose may vary widely, from 100 to 1,600 mg per day. Gabapentin and other chemically-related anti-seizure medications have anti-spasticity properties and are effective in some people. They are frequently used as "add-on" drugs to enhance the effects of other medications such as baclofen.
Additionally, gabapentin may be a useful treatment for dysesthesia (a burning sensation along the nerve) and other painful conditions that may be associated with MS.
Side effects include fatigue, sleepiness, dizziness, and balance problems.
This is an oral medication in tablet form. The dose normally ranges from 400 to 1,000 mg per day. Carbamazepine was also originally developed as an anti-seizure medication. It is especially useful for flexor spasms of the extremities. (Flexor spasms usually affect the lower limbs, often worsening at night, and may be very painful.)
This medication is also used to manage trigeminal neuralgia (sudden and brief periods of severe facial pain, occurring on one side of the face), as well as other dysesthesias.
Side effects include dizziness, drowsiness, nausea, and balance problems.
This is another oral anti-seizure medication that has been found useful for some of the symptoms of MS. A 2003 study of 12 patients at the University of Texas showed a significant improvement in spasticity following treatment with levetiracetam. Three of the 12 also reported improvement in neuropathic pain. The drug was well tolerated; large, well-controlled trials are needed to confirm these findings. Until then, this will not be considered a routine treatment.
Side effects may include sleepiness and dizziness.
This is an oral medication in tablet form. Ropinirole was developed for use in Parkinson 's disease, and is also effective for restless legs syndrome. This may explain its usefulness as a treatment for painful nighttime spasticity.
Side effects include nausea, dizziness, drowsiness or trouble sleeping, constipation, and headache.
PHARMACEUTICAL THROUGH PHYSICAL INTERVENTIONS
Botox® and Myobloc®(botulinum toxin)
Botulinum toxin is administered by injection into a muscle (or muscles) that is involved in severe spasticity, and has almost completely replaced the phenol blocks used earlier for spasticity. It temporarily blocks the nerves that lead to specific muscles, for a period of months. The drug should only be administered by an experienced physician or other healthcare provider.
Side effects may include unexpected weakness.
Baclofen Pump (Intrathecal Baclofen)
When spasticity is severe and does not respond to oral medications, administration of baclofen directly to the spinal cord is often effective. This involves the placement of a tube into the spinal canal that is connected to a pump implanted under the skin. It decreases spasticity with a much lower dose of baclofen than would be needed orally, and with a much lower incidence of Side effects. The most frequent complications of this therapy are catheter malfunction and infections, with a higher incidence of malfunction in people who are ambulatory.
Side effects are the same as those for oral baclofen (details given on page 11), although they are less common because the dose is significantly lower.
In rare instances, when spasticity cannot be resolved through standard pharmacologic management strategies, irreversible surgical procedures may be considered. This involves cutting nerves to specific muscles that do not respond to the procedures discussed above.
|Last Updated on Friday, 10 May 2013 10:34|