Challenging Spasticity in Multiple Sclerosis

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Challenging Spasticity in Multiple Sclerosis

• Francois Bethoux MD
• The Mellen Center for MS
• The Cleveland Clinic

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Spasticity

• Spastikos - to draw or tug
• Movement disorder, caused by malfunction in the
  brain and/or in the spinal cord
• Exaggerated reflexes
• Increased muscle tone
• Abnormal movements

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Mechanisms Leading to Spasticity
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Spasticitypathopharmacology
Descending inhibition Interrupted esp small
peptides, catechols
Muscle stretch receptors functionally sensitized
Muscle afferents Ib mainly GLU lack presynaptic
inhibition
Interneurons Presynaptic inhibition mainly GABA
disrupted. Decreased GABA, increased GABA
receptors
Motorneurons
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Prevalence
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Levels of Spasticity Experienced by MS Patients
Spasticity is a very common symptom among
Registry participants. More than half of the
patients report that it forces them to change
some of their daily activities (moderate) and
for some even to prevent them (severe). n21128
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The Players

• Spasticity
• Patient
• Treatments
• Disease process or injury
• Health care team
• Environment

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Spasticity

• Spasticity of spinal origin
• unresponsive to oral antispasmodics
• and/or experience unacceptable side effects at
  effective doses of oral baclofen
• Spasticity of cerebral origin must be one year
  post brain injury to be considered for ITB
  Therapy
• What is severe spasticity ?

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Consequences of Spasticity
Environment
Activity Limitation(s)
Impairment(s)
Participation Limitation(s) / poor Quality of Life
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Assessment of Spasticity and Consequences

• Impairments
• Active and passive ROM, pictures
• Ashworth scale, Spasm Frequency Scale
• Pain scales
• Gait evaluation timed 25-ft walk, 6-mn walk,
  VGA, videotape, 3D analysis
• Upper extremity NHPT, box and blocks test
• Electrophysiologic tests
• Activity Limitations
• Generic FIM, Barthel Index
• Function- and disease-specific scales
• Participation / Quality of life

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Patient

• The best patients are those whose spasticity
  poses the greatest inconvenience.
• Janet Gianino, R.N., M.S.N.
• Personal characteristics
• Physical factors, comorbidities
• Psychological factors
• Cognitive factors
• Situation in life and in disease course

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Treatments
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Rehabilitation

• Preventive and corrective role
• Complement to other treatments
• Education / home exercise programs
• Modalities
• Stretching exercises
• Walking aids (incl. AFOs)
• Splinting, casting
• Electrical Stimulation

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Antispasticity Medications

• First-line therapy
• Baclofen (Lioresal)
• Tizanidine HCl (Zanaflex)
• Adjuvant therapy
• Diazepam (Valium)
• Clonazepam (Klonopin)
• Dantrolene sodium (Dantrium)
• Clonidine (Catapres)
• Muscle relaxants
• Others

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Local Treatments

• For focal spasticity, or focal consequences of
  diffuse spasticity
• Local anesthetics
• Lidocaine, bupivacaine, etidocaine
• short duration of effect
• potential CNS and CV toxicity, hypersensitivity
• Neurolysis
• phenol, alcohol
• longer duration of effect
• pain, swelling, fibrosis, dysesthesias

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Local Treatments

• Chemodenervation botulinum toxin (A / B)
• upper and/or lower extremity, back, neck, etc.
• EMG / electrical stimulation for muscle
  localization
• guidelines for Botox
• total maximum dose per visit 400-600 Units
• maximum volume per site 0.5-1.0 ml
• reinjection gt3 months
• onset of effect 24-72 hours, peak 1-4 weeks
• duration of clinical benefit 3-6 months

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Local Treatments

• Chemodenervation botulinum toxin (A / B)
• local side effects pain/discomfort with
  injections, muscle weakness, atrophy
• general side effects dry mouth, dysphagia, rash,
  palpitations, etc.
• immunoresistance
• cost
• chances of success increase with careful
  evaluation and clear realistic goals

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Surgical procedures

• Tendon lengthening / tendon transfer
• serial casting or splinting
• stretching
• Neurectomy
• Selective dorsal rhizotomy
• Epidural electrical stimulation
• Intrathecal baclofen (ITB)

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Intrathecal Baclofen Therapy

• Treatment for severe spasticity of cerebral or
  spinal origin
• Usually considered for diffuse spasticity of the
  lower extremities, when oral medications are
  ineffective or not tolerated
• Also used to control upper extremity spasticity
  (higher catheter placement)
• Used in spinal cord injury, traumatic brain
  injury, cerebral palsy, multiple sclerosis, ...

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Intrathecal Baclofen Therapy

• Pump implanted subcutaneously or subfascially in
  the abdomen
• Catheter tunneled to lumbar region, distal end
  inserted intrathecally
• Programmable pump allows simple or complex
  programming, boluses
• Requires periodic refills (Lioresal Intrathecal
  500mcg/ml or 2000mcg/ml)
• Pump will be replaced at battery end of life

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ITB therapy

• Very effective, particularly on spasms
• (Relatively) safe
• Well tolerated
• Adjustable and potentially reversible
• Discontinuation of oral antispastic medications
  may increase energy level

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ITB therapy

• Complications
• Peri-operative
• Infections
• Catheter / pump malfunction
• Drug overdose / withdrawal
• Inconvenience
• Return for dose adjustments / refills
• Replace pump after 5-7 years (battery)
• Repeat surgery to fix system malfunctions
• Risk of increased weakness, loss of function
• Cost

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Traditional use of ITB therapy in MS

• Advanced primary or secondary progressive MS
• EDSS 7.5 or higher (non-ambulatory)
• Often living in NH
• Severe stiffness and/or spasms, contractures
• Beyond reach of oral antispastic medications
• Goal comfort and ease of (self-)care more than
  gain of functional independence

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Disease Process

• Affects the CNS gt spasticity is often associated
  with other neurologic and non-neurologic
  impairments
• Course (stable, progressive, with exacerbations
  /- progression)
• Controlled ?
• Are other treatments likely to interfere with
  spasticity and/or its management ?

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Health Care Team

• Multidisciplinary team ?
• Communication
• within team
• with referring physician
• Experience with treatments for spasticity
• Experience with MS management

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Environment

• Human environment (family, caregivers)
• Physical environment (at home, work, )
• Proximity to ITB center, transportation
• Social environment
• Insurance, financial considerations

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Evaluation

• Multidimensional
• Multidisciplinary
• Comprehensive
• Documentation (notes, videotapes)

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Consequences of Treatment
Participation /Quality of Life
Environment
Activity Limitation(s)
Impairment(s)
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Education

• Patient and caregiver(s) should be thoroughly
  educated about all aspects of spasticity,
  testing, and treatment
• Key points should be repeated
• Patient (and if appropriate caregiver(s)) should
  be part of decision making
• Reasonable expectations should be agreed upon

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Treatment Goals

• Comfort
• Relieve pain or discomfort related to stiffness /
  spasms
• Ease of Care
• Improved posturing, hygiene, catheterization,
  etc.
• Function
• Improve use of affected limbs
• Improve ability to perform ADLs and IADLs
• Handicap and quality of life improve or preserve
  ability to fulfill roles (mobility, work, family,
  leisure activities), improve or maintain quality
  of life

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Planning Spasticity Therapy

• Consider all available therapies
• Combine therapies if necessary
• Anticipate the results of therapies
• Plan one step ahead
• Make sure everybody is on the same page
• Adjust expectations and plan of care over time

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Timing interventionsusing the threshold model

• Evolution of disability and handicap is not
  linear in MS
• Individuals reach thresholds that will result in
  significant modification, or loss of a function
• The role of medical and rehabilitative
  interventions is sometimes to bring patients back
  below a threshold, more often to avoid or delay
  reaching a threshold

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Example of walking ability
Wheelchair
Walker
Cane
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Contributing Factors
Environment
Disease
Psychological
Threshold
Iatrogenic
Comorbidities
Trauma
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Corrective / Preventive Factors
Rehabilitative Interventions
Psychological Interventions
Medical Interventions
Threshold
Interventions on environment
CNS plasticity
Patient adaptation