Managing and treating spasticity and spasms
Louise Jarrett, spasticity nurse specialist
Open Door - November 2008 pages 5-7
This is the second of two articles on spasticity. The first part was published in the August issue of Open Door. That article described the nature of spasticity, spasms and its associated features of pain and weakness. It highlighted that key elements to successful management are the need to incorporate movement, stretches, good sitting and lying postures and the ongoing management of trigger factors. This article will focus on the available drug treatments and their potential use to optimise management.
Getting the most from taking drugs
The effective use of drugs can be an invaluable part of how a person manages their spasticity. When commencing any drug to manage spasticity it is best to start with a low dose and gradually increase it, until a dose is reached that helps but does not cause side effects. The oral drugs available (see table below) can be used in combination, but usually a doctor will maximise the effect of one drug before prescribing it with others. The doses in the table are only a guide. A doctor will specifically prescribe a drug, the dose to take and how to increase it for each individual.
Anti-spasticity drugs are most effective when they help a person to function more easily. It is important to consider the best time to take these drugs during the day. For instance if getting out of bed is difficult, it could be beneficial for someone to have their drugs next to the bed, take them when they wake up and wait 10 - 20 minutes before getting up.
A research trial has investigated reports that cannabis might reduce spasticity and spasms in MS1. Unfortunately the research was inconclusive and cannabis remains currently unlicensed for use in the UK.
| Drug | Site of action | Initial and maximum doses | Side effects |
|---|---|---|---|
| Baclofen | Directly on nerve cells, mainly in the spinal cord, to decrease the excitability of the nerves and therefore reduce excessive muscle activity including spasms | Initial dose 5-10mg once or twice a day. Maximum dose 120mg | It works for between 4-6 hours so needs to be taken regularly through the day. It should not be stopped abruptly as this can induce seizures. Side effects can include weakness, drowsiness and dizziness |
| Gabapentin | Central nervous system | 100-300mg daily up to a maximum of 2400mg | Drowsiness, dizziness |
| Tizanidine | Central nervous system | 2mg daily up to a maximum of 36mg | A doctor will initially recommend regular blood tests to ensure it does not have any adverse effects on liver function. It can also cause drowsiness and a dry mouth |
| Diazepam | Central nervous system | 2mg daily up to a maximum of 40-60mg | As a prominent side effect is drowsiness this drug is best taken at bedtime. Side effects include reduced attention and memory impairment. Should not be abruptly stopped as this can cause withdrawal effects |
| Clonazepam | Central nervous system | 0.25 - 0.5mg daily up to a maximum of 3mg | As a prominent side effect is drowsiness this drug is best taken at bedtime. Side effects include reduced attention and memory impairment. Should not be abruptly stopped as this can cause withdrawal effects |
| Dantrolene | The only anti-spasticity drug that works directly on muscles | 25mg daily up to a maximum of 400mg | Side effects are unfortunately quite common and include nausea, vomiting, diarrhoea and weakness. A doctor will take regular blood tests to ensure that the function of the liver is not affected |
(Adapted from Stevenson and Jarrett 20063)
What if the oral drugs don't help?
If management strategies, therapy input and oral drugs are not providing adequate relief from spasticity, then the following treatments may be considered.
Intramuscular botulinum toxin (BT)
When BT is injected into muscles it temporarily weakens them. It can take 14 days for the full effect of the toxin to occur and it lasts approximately three months. When combined with an intensive period of moving and stretching this can lead to a reduction in spasticity over longer periods. Advice on a specific stretching program is best provided by a physiotherapist or occupational therapist around the time of the injections.
Intrathecal baclofen therapy
Intrathecal baclofen therapy is an alternative way of delivering baclofen directly to the appropriate nerve cells in the spinal cord. In the short term intrathecal baclofen can be given via a lumbar puncture. For long-term treatment an implantable pump is required to deliver baclofen 24 hours a day. The system is completely implanted inside the person with the pump surgically placed in the abdomen. It has a reservoir which stores the baclofen and a catheter which links the reservoir to the intrathecal space (the space around the spinal cord within the spine). Different types of pump are available but in essence the baclofen is pumped into the spine either electronically or via a gas-compression system. The pumps enable much smaller amounts of baclofen to be used, reducing any side effects that a person may have experienced when taking baclofen orally. This can be helpful for those people who find they cannot tolerate oral baclofen.
Intrathecal baclofen pump and catheter
Embarking on intrathecal baclofen therapy is not a simple decision to make. Not only does it involve surgery but also regular reservoir refills and, if using the electronic model, further surgery after approximately 5-7 years when the battery depletes. Helpfully, before implantation, a trial of the drug can be given via a lumbar puncture. This gives the person, their family and the treating team the opportunity to experience and assess the potential outcome of having intrathecal baclofen before committing to the surgical pump implant.
Intrathecal phenol
This treatment tends to be reserved for severe spasticity that is not responding to other forms of treatment. Intrathecal phenol is given via a lumbar puncture by a specialist doctor. Intrathecal phenol is a destructive treatment that, when injected into the intrathecal space, stops nerve conduction. This can significantly reduce lower limb spasticity but other negative effects can occur such as a reduction of leg sensation, reduced sexual function, and altered bladder and bowel function. People suitable for intrathecal phenol will already be experiencing a change in these specific areas and will have effective management strategies in place, for instance a suprapubic catheter or regularly use suppositries, so that the use of intrathecal phenol will not cause any negative impact on management regimes.
Surgery
Occasionally a neurologist may recommend orthopaedic or neurosurgical procedures, although these are becoming more rare.
Measuring the impact of treatments
To help understand if a particular drug or stretching regime is helping a person's spasticity and spasms, health care professionals may ask to 'measure' a person's symptoms. 'Measures' are tools that use numbers or words to classify or quantify symptoms. The purpose of using measures is to compare the person's degree of spasticity, spasms and pain over time or before and after treatments. In the case of intrathecal drug trials the measures can guide the person, their family and the team to appreciate the potential impact of proceeding with an intrathecal treatment.
Spasticity measures
There is no one measurement tool or scale that adequately measures spasticity. In practice, a series of measures is often required to reflect different aspects of spasticity.
These approaches will look at different aspects of the symptoms:
- Moving limbs to physically measure the distance that they can be moved
- Asking the individual to report on how they are affected by their symptom - eg the Penn Spasm Frequency Scale involves the individual reporting the type and frequency of spasms
- Assessment of symptoms by a health professional - eg the Ashworth Scale involves the measurer moving a limb through its available range and assessing the level of stiffness
How can it feel to be measured
When measuring spasticity, the health care professional concentrates on the degree they can move a limb and how it feels when they do so. They may ask the person to focus on their main problem and what in relation to their spasticity would improve their current lifestyle. They may discuss the measures with others, using numbers that may have little or no meaning to the person being measured.
Evaluating and measuring spasticity in partnership
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 they may not normally do; this can be emotional, challenging and at times distressing. For other's the measuring process helps them to be more specific about changes they feel in their bodies or the impact on their lifestyle. Health care professionals are advised to be alert to how a person may be feeling and provide support through education, engagement and involvement to enhance the measuring process2. Education involves explaining why measurement is required, how it will help the team assessment and what the person's role is in it. Being involved in the process allows the person to share how they are experiencing the changes in their spasticity and spasms and how this may affect their function at home. It's important to remember 'being measured' is not a test and there is no right or wrong. It is just a baseline for comparison.
In summary, effective spasticity management requires ongoing management of posture through movement and stretches, the management of trigger factors and the careful evaluation and use of drug treatments.
References
- Zajicek J, et al.
Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial.
Lancet 2003; 362:1517-1526. - Jarrett L.
The challenge of managing spasticity: the role of the nurse in the process of assessment and measurement?
Nursing Times 2006;102(15):26-28. - Stevenson VL, Jarrett L.
Spasticity management: a practical multidisciplinary guide.
Oxford: Informa Health Care; 2006.
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Open Door articles are reproduced as published. They are not updated to take account of subsequent developments. Use appropriate caution in acting on the information in any article.