Typically, the doctor will increase the dose of medication gradually until the full benefit is evident, and reduce the dose if side effects occur. In addition, people on your health-care team can suggest timing your medication in specific situations. For example, taking an antispasticity medication an hour before sexual activity can prevent painful spasms during orgasm.

• Baclofen Baclofen (Lioresal®) is a muscle relaxant that works in the spinal cord. It is most often taken three or four times a day, and common side effects are drowsiness and muscle weakness. Baclofen relaxes normal as well as spastic muscles. Nausea, a less common side effect, can usually be avoided by taking baclofen with food. The drug has a good safety record with long-term use. The side effects don't build up or become worse over time. At high doses, this medication reduces concentration and contributes to fatigue.

Because it usually restores flexibility within a short period, baclofen may allow other treatment, such as physical therapy, to be more effective. Baclofen does not cure spasticity or improve coordination or strength. A gradual increase in dosing often allows for higher and more effective doses to be taken. It should not be greatly reduced or stopped suddenly without consultation with your physician.

• "Intrathecal" baclofenSome people require a higher dose of baclofen but cannot tolerate the higher side effects. A surgically implanted pump can administer very small amounts of the drug directly and continuously to the spinal cord (specifically to the fluid which surrounds the cord).

The baclofen pump has been extremely successful. The pump can improve (or at least maintain) a person's level of functioning. It may even help some people remain ambulatory. And it permits people with very limited mobility to be positioned to minimize pain and the risk of skin breakdown.

The computer-controlled, battery-operated pump, which weighs about six ounces, is surgically implanted under the skin of the abdomen. A tube runs from the pump to the spinal canal. The pump is programmed to release a pre-set dose specific for the individual. People who use the pump are seen by their physician or nurse for a new drug supply and a check of the computer program every one to three months. New drug is injected into the pump through the skin. The little computer can be reprogrammed painlessly by radio signals. When the battery wears out (in three to seven years) the pump itself is surgically removed and replaced. The tube remains in place.

• Tizanidine Tizanidine (Zanaflex®) works quickly to calm spasms and relax tightened muscles, but may cause greater sedation than other medications. Tizanidine is typically taken three times a day. In addition to drowsiness, dry mouth is a common and usually temporary side effect. Hypotension (low blood pressure) is another potential side effect although less frequent.

This drug also has a good safety record with long-term use. It does not cure spasticity or improve muscle coordination or strength. A combination of baclofen and tizanidine may give the best results. Tizanidine should be used with caution with ciprofloxacin HCI (Cipro®), which is used to prevent or treat urinary tract infections, since increased drowsiness or sleepiness can occur.

• Diazepam Spasticity can also be treated with diazepam (Valium®), generally in small doses. This drug is not as effective as those mentioned above, but it has the benefit of relieving anxiety, making it easier for someone who is restless or has disturbing night-time spasms to relax and get a good night's sleep.

Drowsiness and potential dependency with long-term use make diazepam a less desirable choice. However, in some circumstances, diazepam and another antispasticity drug may be prescribed together. People for whom this works say that they would rather be a bit sluggish and fully flexible than wide awake and spastic. Clonazepam (Klonopin®), can also help control spasms, particularly at night.

• Gabapentin Gabapentin (Neurontin®) is used to control some types of seizures in epilepsy. In MS it controls certain types of pain, and can reduce spasticity. The most common side effects include blurred or double vision, dizziness, and drowsiness. Once you've started on it, gabapentin should not be stopped without consulting your physician.
• Dantrolene Dantrolene (Dantrium®) is generally used only if other drugs (alone or in combination) have been ineffective. It works by partially paralyzing muscles, making it a poor choice for people who walk. Dantrolene can produce serious side effects, including liver damage and blood abnormalities. The longer a person takes this drug, the more these problems are likely to develop. People taking dantrolene must have periodic blood tests.
• LevetiracetamLevetiracetam (Keppra®) is another drug used for seizure control in some forms of epilepsy. In MS, it can sometimes be helpful in improving spasticity and spasms in MS. Side effects and treatment considerations are similar to those seen with gabapentin.
• Botulinum toxin Injection of botulinum toxin (Botox®) has been shown to help spasticity. However, the benefit is limited to the injected muscles, and the treatment must be repeated every three to six months. Only small amounts of the drug can be injected into the body at any one time. Otherwise, the immune system might create antibodies against it. For these reasons, Botox is not a good choice when many muscles are spastic or the spastic muscles are large. It is a very good choice when muscles of the arm are spastic, as these muscles are small and do not require a lot of medication. Side effects include weakness of the injected muscle and some nearby muscles, and a brief "flu-like" syndrome. Despite the drug's effectiveness, the FDA has not yet approved Botox for MS-related spasticity, and the drug is very expensive.
• Phenol Another treatment is the injection of a nerve block called phenol. This treatment also needs to be repeated every three to six months, and is often effective when oral agents have had unsatisfactory results.

VI. A FINAL OPTION

Severe Spasticity

Enormous progress has been made in controlling spasticity in the past two decades. If none of the treatments discussed above have helped, surgery might be recommended for relief. The relief is permanent, but so is the resulting disability. The techniques include severing tendons (tenotomy) or nerve roots (rhizotomy) in order to relax cramped-up muscles. These measures are only undertaken after serious consideration and for the most difficult cases of spasticity.