Posted by: Thixia | October 23, 2008

Spasticity in MS 4 of 9

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. 


Emphasis must be placed on the fact that it is not a test and there is no right or wrong.  MS in


 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.   



Treating spasticity 


The most important principle of treating spasticity is to develop reasonable and flexible goals that target specific manifestations of spasticity – pain, fatigue, stiffness or weakness – and, together with the person with MS, frequently reassess the effectiveness of treatments.    


Spasticity can affect just a few parts of the body (focal spasticity), or it can manifest in multiple places (generalised spasticity).  It can range from insignificant to incapacitating, with many levels in between.  Spasticity can also increase and decrease.  Many people with MS recognise increased spasticity as a sign of a bladder or other infection, or of the increase in core body temperature that is associated with a fever or excessive exercise, or of a full bladder or colon.  Other causes of increased spasticity include: l noxious stimuli such as a skin lesion l a bladder or kidney stone l fractures l tight clothing l menstruation l psychological stress l extreme environmental temperature l hunger l an MS exacerbation l treatment with some disease modifying or antidepressant pharmaceutical agents.  It is important that people with MS and their healthcare team examine reasons why spasticity may suddenly increase and address them appropriately.  If there are no recent changes in health that could explain an increase in spasticity, then it is reasonable to think about different approaches to managing spasticity and this does not necessarily mean medication.  Often the simplest way for many to reduce muscle tightness and soreness is with rangeof- motion exercises and stretching.  Maintaining range of motion can be done with a regular home exercise programme, home physical therapy programme or through a community-based exercise class.  Ice has also been shown to reduce spasticity in some studies, and the application of local heat can aid in stretching, although there is a lack of consensus about how often and long to stretch. 



Oral medications


A number of medications have been used to treat generalised spasticity.  Although there is variability in response to and tolerability of different medications, most practitioners will suggest baclofen as a first line agent.  It works at the level of the spinal cord to help the body inhibit muscle movement.  A number of studies have shown that baclofen is effective in reducing pain, improving gait and overall function, as well as decreasing spasm frequency.  However, baclofen can cause fatigue, dry mouth, dizziness and nausea and many people start on baclofen and say it doesn’t work for them.  However, if assessed carefully and consideration is given to dose and timing, the results may be more positive.  A written regime, with slowly increasing doses that help a person with MS assess how baclofen affects them over a period of time, and regular review can make the use of baclofen much more successful.  Even so, some people with MS still find they cannot tolerate the dose of baclofen required for efficacy because of the side effects.  Another medication clinicians frequently prescribe is tizanidine.  Again starting at a low dose, tizanidine appears to be particularly effective for painful spasms at night.  Like baclofen, it can cause sleepiness, dry mouth, dizziness and fatigue.  Diazepam is also effective in treating spasticity in some people.  It appears to have a greater risk of causing sleepiness and muscle weakness, and it has the potential for dependence and addiction which can affect adherence.  Dantrolene can be used for spasticity and it works at the level of the muscles to limit contractions.  Besides sharing most of the side-effects of diazepam, baclofen and tizanidine, dantrolene also requires frequent laboratory monitoring to ensure the medication does not damage the liver.  As a result, dantrolene is not prescribed as frequently as the other medications.  Other medications that may be prescribed include clonazepam and gabapentin, although again, side effects can be problematic.  A combination of therapies may also be helpful for some people, and this approach has become increasingly utilised by clinicians. 



Compliments of:


Multiple Sclerosis International

Federation (MSIF)


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