Posted by: Thixia | October 22, 2008

Spasticity in MS 3 of 9

Managing spasticity


It is particularly important to approach spasticity management from an interdisciplinary team approach (neurologist, nurse, rehabilitation physician and other rehabilitation specialists), including the person with spasticity and their caregiver.  An interdisciplinary team can better identify goals and make the adjustments necessary to attain optimal spasticity management.  Goals of spasticity management should be orientated towards the improvement of function and improved comfort, and an individual’s response to interventions such as medications, rehabilitation or surgery should be closely monitored. 


With close monitoring and the involvement of an interdisciplinary team, adjustments can be made according to changes in spasticity and function.  Medications can be increased or decreased, appropriate adaptive equipment can be recommended and training provided, and other interventions can be explored.  When treating spasticity it is important to focus goals on management and not necessarily on the elimination of the spasticity since some individuals use their spasticity to assist with functional movements.  In addition, for individuals who have restricted movement, spasticity may help promote circulation by maintaining muscle contractions which can promote the return of blood to the heart.






People with MS may experience many different symptoms during the course of the disease, and spasticity is one of the most common.  However, spasticity is often a treatable symptom and can be managed to decrease its adverse effects on overall function.  Utilising a team approach can be very effective for proper identification, goal-setting and appropriate interventions.


Spasticity can interfere with gardening, exercising, and performing activities of daily living.



Evaluating and measuring spasticity



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 stiff 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 There is no one tool that adequately measures spasticity.  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 no meaning 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. 


Compliments of:


Multiple Sclerosis International

Federation (MSIF)


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