Local treatments for spasticity

For those with spasticity affecting a small area (focal spasticity), or who do not get relief from oral medications, local injections of botulinum toxin or phenol into the muscles can improve quality of life.  A typical example of spasticity treatable with botulinum toxin would be the overactivity of muscles that flex the wrist, reducing the ability to reach and grasp objects.  Making those muscles weaker can improve both function and pain.  There are two types of botulinum toxin, type A, known as Botox® in the United States and Dysport® in Europe; and type B, Myoblock®.  A local injection of botulinim toxin can last 3–6 months and make functional activities easier to undertake.  Phenol or alcohol blocks are done less frequently, and involve identifying a point where nerve and muscle meet.  Phenol is injected to destroy the nerve endings in that area only.  With both phenol and botulinum toxin, the effects are temporary and may require frequent injections.  Also, individuals can build up antibodies to the botulinum toxin over time, making it ineffective.  Some people are able to switch from the type A toxin to type B to prolong the therapeutic effect.  The most appropriate treatment plan usually includes work with a physical and/or occupational therapist after the injection to improve functional movement of the affected area.   

Surgery for spasticity

Often the simplest way for many to reduce muscle tightness and soreness is with range-of-motion exercises and stretching

Orthopaedic surgeons and neurosurgeons might get involved in the management of spasticity in two ways.  If a person experiences spasticity that has caused permanent deformity, a surgeon can.  lengthen tendons or fuse joints or otherwise address malformations.  Surgical correction of deformity coupled with proper rehabilitation interventions can prolong sitting times in a chair, prevent skin breakdown or its recurrence, and reduce pain.  Surgeons can also contribute to the care of a person with MS who is a candidate for intrathecal baclofen therapy (ITB).  Generally reserved for those who have lower extremity spasticity and do not have an adequate response to medication or who are unable to tolerate them, ITB involves the placement of a catheter into the thecal sac, a space around the spinal cord.  The catheter connects to a reservoir and pump that has been placed under the abdominal skin.  The pump delivers medicine directly to the spinal cord, which for most people provides relief from spasticity without the side effects caused by the oral form of baclofen, such as fatigue and drowsiness.  Although ITB was originally used primarily in people with severe spasticity who could no longer walk, it is now also used to help improve walking in some people with MS.  Evaluation for this kind of intervention should, ideally, take place at an MS centre or a clinic where experienced providers and therapists can make initial assessments, trial test doses and adjust for the best functional outcomes.  If a person with MS and the healthcare team decide to investigate the value of an ITB, the person will first be given a test dose of the medication via a lumbar puncture to gauge response.  With an appropriate response, the person will be scheduled for surgery to permanently implant the pump and the catheter.  The medication will be titrated for best effect.  Refills are done by subcutaneous injection into the pumps port.  The frequency of refills ranges from monthly to twice a year, depending on the dose necessary to achieve an optimal effect and the size of the pump reservoir.  Pumps can remain in place for 5–7 years, at which time the batteries wear out and need replacement.  It’s important to note that any abrupt withdrawal of baclofen therapy, oral or intrathecal, can lead to seizures.  Those who are considering ITB should know the warning signs of a low or leaking reservoir.  Oral baclofen doses similarly need to decrease under expert medical supervision.  Optimising management of spasticity can have a dramatic impact on the quality of life of people with MS, through a reduction of pain, weakness and muscle inefficiency.  If a person with MS has troubling spasticity, working with the healthcare team to identify clear goals for treatment, adjusting treatments as needed, and understanding that spasticity will probably change over time will set the stage for the most effective interventions and the most satisfactory outcomes. 

Optimising management of spasticity can have a dramatic impact on the quality of life of people with MS.  ITB involves the placement of a pump under the abdominal skin and a catheter into the thecal sac.   

Compliments of:

Multiple Sclerosis International

Federation (MSIF)