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Symptom Management: Spasticity

SYMPTOM MANAGEMENT: SPASTICITY
Herman J. Weinreb, MD

Spasticity is a common, often disabling symptom in MS. There are only a handful of treatment methods available, and frequently a combination of antispasticity treatments is far more effective than any single one. When the physician, therapist, and patient approach the problem together, spasticity can be significantly diminished.

What is spasticity? A spastic muscle is like an overcoiled spring, which contracts with a sudden, jerky movement and is difficult to stretch. Patients who are spastic usually report a feeling of tightness or stiffness in their legs and some times their arms. Occasionally, the legs will cramp up and go into spasm ("flexor/extensor" spasms) which can be quite painful and disrupt sleep. Spasticity can also interfere with urination or bowel movements, and can make it difficult to have sexual intercourse, to clean the genital region, or to insert catheters or enemas.

Neurologists associate spasticity in MS with a resistance of the limbs to passive or rapid movements--and heightened reflexes. The gait of spastic patients is often stiff-legged and effortful, with loss of grace and agility. Spasticity can increase markedly with obvious or silent urinary tract infections, chronic constipation, fever or other systemic illnesses, and can fluctuate considerably over the course of the day.

MEDICATION THERAPIES

Baclofen is most frequently used to treat spasticity, and works best when damage to nerve pathways in the spinal cord is the source of the spasticity. Baclofen resembles the natural nerve transmitter gamm-aminobutyric acid (GABA), and probably works by inhibiting overactive nerve circuits in the spinal cord. Unfortunately, many patients cannot tolerate even small doses--baclofen can cause drowsiness, increased weakness, or mental clouding. Some patients depend on their spasticity to stand up, and excessive baclofen will cause weakness that interferes with standing. While usual baclofen regimens range between 40-80 mg a day in split dosages, some patients may require daily doses as high as 200 mg. Patients should be aware that sudden withdrawal of high daily doses of baclofen can result in delirium, even seizures, and that baclofen requirements can vary daily and should be adjusted continually by a neurologist.

There are few alternatives to baclofen. Medicines such as diazepam (Valium) or clonazepam (Klonopin) must be taken in fairly high doses and can cause excessive sedation, impair memory, and be addictive. Dantrolene (Dantrium), considered a "third line" agent for spasticity, acts directly on muscles and must be monitored by frequent blood tests because it can cause serious liver damage. In some persons cyclobenzaprine (Flexeril), opiates, clonidine, and the amino acid L-threonine are occasionally helpful. A new drug available in Europe, tizanidine is now under investigation in the U.S. and may be approved for release in 1995.

PHYSICAL THERAPY

An essential component for managing spasticity: regular physical therapy in a supervised program of active and passive motion in the affected limbs. Active stretching programs and yoga can be enormously helpful if done faithfully. Swimming is particularly effective in improving range of motion and in reducing muscle stiffness. And occasionally wrapping the involved limbs briefly with ice packs can reduce spasticity for up to 24 hours.

OTHER THERAPIES

Severe spasticity requires more aggressive intervention. Obturator nerve block is a simple, effective technique in which a substance such as phenol or alcohol is injected into the thigh nerve to paralyze the hip muscles. The effects are temporary and limited to the hip muscles.

In dorsal rhizotomy, sensory nerves adjacent to the spinal cord are surgically sectioned off to reduce the cord's sensory input and consequently reduce spasticity. This method can be effective but it is irreversible.
Electrical stimulation of the spinal cord through an implanted electrode carries a significant risk of infection or dislodgment, and its efficacy hasn't been established.

Injection of botulinum toxin directly into spastic muscles, though it's not effective when one or more entire limbs are spastic. In addition, this treatment may also cause local paralysis lasting weeks or months. PAIN
This material is provided as general medical information and is NOT intended as advice for individual patients; please contact your physician for specific recommendations.

QUESTION: I have constant pain and extreme tightness in my feet at all times. My feet simply hurt and feel like they are always "making a fist." The feeling resembles sticking your feet in a bag of sharp nails. Massage helps some, but my doctors haven't found a medication yet to help lessen the effect. This feeling is driving me nuts - any suggestions?
7/10/98 ANSWER: You sound like you're suffering from a neuropathic pain syndrome that can be common in MS. This is generally managed with a variety of medicines, either alone or in combination: tricyclic antidepressants, anticonvulsants Tegretol, Dilantin, Klonopin, Neurontin, Lamictal, etc. Often, these medicines have to be given in combination for adequate benefit and relief. Giving them in combination also reduces the side effects and total doses needed.
QUESTION: I have a very unusual symptom in my MS that has really puzzled the doctors. It is an acute, sharp, stabbing, usually shooting, pain in my left arm. It is very severe when it flares up. The pain itself lasts seconds at a time, and it usually goes away after three or four weeks. One doc says it's like trigeminal neuralgia, but in the arm instead of the face. He believes it's very unusual. I would like to know your thoughts on this problem.
7/10/98 ANSWER: Your doctor is correct. I see neuralgic limb pains all the time in MS. They can mimic trigeminal neuralgia exactly except for their location. It is important to ascertain that there is not a tumor like a Schwannoma or other arthritic irritation in the area of the nerve involved. This is usually accomplished by MRI study. Fortunately, most of these lesions tend to run their course and eventually subside. Sometimes they persist for quite a while. When necessary they do respond to anticonvulsants such as Tegretol, Dilantin, and even Neurontin, Lamotrigine, and baclofen.

QUESTION: I am 32 years old, diagnosed approximately seven years ago. However, I live with extreme pain in my left leg, the main nerve, and it is intense, like a lightening bolt of pain. I take painkillers, which mask but do not solve it. I have had extensive testing and even a MRI on a portion of my leg just below the knee where even the simple task of putting on panty hose can set me off into intense pain. When I am suffering, which is most of the time, it shoots up my back and sometimes into my stomach. I have even had sharp, horrible pains in my breast that to laugh would be breath taking. I have had pain since I was in my early teens. In my research I have not found anyone like this with MS. I have the many other symptoms of MS, but not very bad, only at times, few and far between. But the pain is beyond words and I would appreciate any advice or recommendation given. I will search anything and everything out!
7/10/98 ANSWER: Neuralgic-like pains which you are describing are not at all uncommon in MS but the average neurologist who is following only about a dozen patients is not going to have much experience with them. I follow 1000+ patients and see these quite commonly. I think of them as a form of trigeminal neuralgia in the limbs, not in the face. The first order of business is a spinal cord MRI to try to identify the nature of the lesion causing the pain: not everything is due to MS! The second maneuver involves the use of various medicines alone or in combination for neuralgic pain. In this condition, unfortunately, a variety of medicines have to be put together. This cocktail can involved tricyclic antidepressants, anti-convulsants such as lamotrigine and gabapentin, and even anti-arrythmics. There is some evidence that even dextromethorphan, the active ingredient in Robitussin, can be helpful. You need to put yourself in the hands of an expert in pain management in MS, someone who believes in your pain and the intense suffering and lifestyle havoc it is creating.

QUESTION: When is it time to switch medications? I have been taking Baclofen® for 3 weeks now and am up to 90 mg per day. It is not helping. I am in severe pain all the time and the doctor seems to think this is acceptable. I have spasticity in my arms, hands, legs, feet and neck. What else could I be taking and should Baclofen® be continued when it is not working?
4/24/98 ANSWER: You live in your body and with your pain, not your doctor! You are entitled to satisfactory pain relief. Baclofen® has some analgesic properties but is primarily an anti-spasticity agent. Tizanidine (Zanaflex®) also relieves spasticity and has some anti-pain effects. It works nicely alone or together with Baclofen®, as does clonazepam. So you have several options to be pursued.

QUESTION: As you know there are a lot of pain syndromes in M.S. I have a feeling that I am coming out of my skin, a feeling of flu-like heaviness that makes me have to get home fast and get to bed. When I get to bed I feel no better. I have tried Neurontin®, Tofranol®, Tegretol®-all just make me sleepy. But Ultram® relieves that feeling. Is Ulram® an opiate, is that why I feel better? And if so, will I have to up the dosage every week? I currently take 75mg twice a day.
4/16/98 ANSWER It's not clear to me that the symptoms you are describing are pain: jumping out of your skin, flu-like heaviness-where's the pain? Ultram is a unique compound for chronic pain conditions that has both opiate and antidepressant properties. Could it be that you are medicating yourself for anxiety-depression and not for pain?

QUESTION: Lately I have been experiencing pains in left side and heart burn like pain between shoulder blades and pain in ribs. Its merely bothersome most of the day and worsens considerably at night. Do other MS persons experience these symptoms? I had a urinary infection for the first time in my life and thought the pains would go away with treatment. The doctor said the pains in my sides were from the MS. (Jeanne)
3/16/98 ANSWER: MS can cause pain in over 50% of individuals, and sometimes present as a burning, squeezing pain like a vise or corset around the chest or abdomen. This type of pain is termed "neuropathic pain," implying the nervous system damage as its source. It is important to exclude such things as heart or stomach sources for the pain. In some instances, and MRI of the cervical, thoracic, or lumbar spine can be helpful in confirming the presence of a plaque and determining its activity and extent. Treatment of such pain usually involves combinations of tricyclic antidepressants, anticonvulsants, steroids, opiates, and other analgesics; "polypharmacy," or the use of multiple pain medicines to quell the pain is the rule, not the exception, and it would be unusual for one medicine alone to provide satisfactory pain relief.

QUESTION: I am experiencing tightness (constant) and pain (occasional) surrounding my trunk. I feel as though a tight wide band encircles my ribcage, radiating around from my spinal column to my sternum, at times making breathing laborious. My neurologist is not sure if it is a symptom of MS. Are you familiar with this problem and possible treatments? (C. J)
2/16/98 ANSWER: It is not uncommon for MS to manifest as a dysesthetic pain syndrome, sometimes described as a gripping, vice-like sensation around the trunk or a limb. This is usually due to a lesion in the spinal cord relevant to the part of the body involved. An MRI of the spinal cord at the level of the trunk involved, which sounds like T4 in your case, can show the lesion and can exclude a tumor or other abnormality. The symptom, while distressing and distracting, is usually self-limited and tends to dissipate over time. In some cases, a trial of a tricyclic antidepressant (e.g., nortryptiline) or an anti-convulsant (e.g., carbamazepine) will provide substantial symptom relief.

QUESTION: I suffer from extreme neck pain at the base of my skull. My head also becomes extremely heavy to hold up. I get a lot of tightness and pain in my shoulders and shoulder blades. The neck pain and heaviness of my own head are what concerns me most. I am 29 yrs old. I was diagnosed with ms in 11-1994. I suffered paralysis on my entire right side, arm, leg, speech, severe eye pain, facial numbness on right side. I was put on Betaseron®, then started on Avonex® over a year ago. I take Zoloft®, Amantidine®, Corgard®, mag-ox, Tegretol®, and Naproxen® as needed. Is it common to suffer from such severe neck pain, and heaviness of my own head? (Christine)
1/23/98 ANSWER: Pain is not at all uncommon in MS, and may arise from a variety of sources. Neck pain could be due to a lesion in the cervical spinal cord, tightness of the neck muscles due to spasticity or abnormal postures required to walk, irritation of the nerve roots as they exit through the bones of the cervical spine, or irritation of the muscles and ligaments of the neck. Some persons with MS have a tension-type headache syndrome, with tightness and heaviness in the back of the head. Most of the patients I follow with MS report low back pain or leg pains, mostly related to abnormal stresses on the bones, muscles, ligaments, and joints caused by the MS. Whatever the cause, you are entitled to have your symptoms taken seriously and relief of your pain should improve your quality of life.

QUESTION: One of my doctors think that the constant pain I have in the head, neck and back is not related to MS. However, I have not experienced this outside of an attack. which I am currently in. This feels MS related to me. What do you think? (John)
1/3/98 ANSWER Despite the common perception of physicians and patients, MS is not a painless disorder. In one study of a large clinic population, 55% of patients with MS had pain at some point in their disease course. Pain in MS can be acute or chronic, and is attributable to a variety of sources. It can come from ongoing inflammation within the central nervous system, such as in the spinal cord or cranial nerves (trigeminal neuralgia is a good example), and from the consequences of impaired walking. Many older patients with longstanding MS may show signs of advanced arthritis in the spine causing chronic low back pain. Unfortunately, having MS does not make one immune to other problems, so it's important to "think outside the box," and consider other possibilities for pain: unrelated tension headaches, medication effects, etc. I find many patients having unrecognized spasticity due to MS, which can mimic the joint pains and tenderness of arthritis. They report joint stiffness and tenderness without swelling, sometimes with back and neck pain due to the tight muscles of spasticity.