Spasticity is a common symptom in MS patients and those with other neurological diseases. It can result from MS lesions (plaques) in either the brain or the spinal cord. Spasticity is characterized by an increase in the resistance to the passive stretch of a muscle (i.e., when the examiner is stretching the muscle and the patient is relaxed). It is particularly conspicuous when the muscle is stretched rapidly (i.e., the resistance is “velocity-dependent”). In addition to causing muscle stiffness and decreased coordination, it is also associated with extremely painful spasms (intense muscle contractions), which can result in significant disablility.
Non-medicinal approaches to the treatment of spasticity include stretching, range of motion exercises, and aqua therapy and these can be very helpful. They should be tried in most cases although, when these approaches fail to provide adequate relief, trials of oral medications such as baclofen, tizanidine, or diazepam (see section on symptom management) should be undertaken. Nevertheless, in some patients, spasticity is resistant to these measures and, in these situations, it may respond to the administration of either botulinum toxin or intrathecal baclofen.
Intramuscular Botulinum Toxin
Botulinum toxin is available in several different formulations including onabotulinum toxin type A (Botox); incobotulinum toxin type A (Xeomin); and abobotulinum toxin type A (Dysport). Botulinum toxin is a protein produced by the bacterium Clostridium botulinum and which causes weakness of skeletal (voluntary) muscles. It has been FDA-approved for the treatment of upper limb spasticity since 2010.
Botulinum toxin injections can help with spasticity in the arms and legs, and with muscle spasms in the lower back. The medication is injected directly into the muscles that are affected by spasticity. The procedure is quick, and there tend to be no side-effects. It typically takes 5-10 days for the medication to start working, and the therapeutic effect lasts for 2-3 months. Re-treatment can be safely undertaken as often as every 3 months, if necessary.
If too much medication is used, the injected muscle could become excessively weak. For this reason, at your first visit, you will be treated with a low dose of botulinum toxin and your response assessed over the next several weeks.
Intramuscular botulinum toxin can be a very effective therapy for the treatment of spasticity, especially when this is severe. However, like any medication, intramuscular botulinum toxin is not the best choice for every one who has spasticity. Your neurologist can evaluate you and refer you to our Botulinum-Toxin clinic if this therapy is considered appropriate.
Intrathecal Baclofen (ITB)
If a patient has spasticity affecting many muscles and has not responded adequately to oral or or botulinum therapy, he or she may be a good candidate for placement of a pump to administer intrathecal baclofen (ITB). This approach injects Baclofen via a catheter directly into the cerebrospinal fluid in the lumbar region (low back). The catheter is connected to a small pump, which is implanted under the skin of the abdomen. Because the delivery of drug is very close to the site of its action (i.e., the spinal cord), patients can get an adequate relaxation of the spastic muscles with miniscule doses – as little as 1/100th of the typical oral dose. This increased effectiveness results in better relaxation and fewer side effects (e.g., drowsiness and weakness) compared to oral medications.
The ITB Program at UCSF is a multidisciplinary team effort, which provides up-to-date, comprehensive care for the management of spasticity. Individuals interested in receiving more information or a DVD describing ITB therapy, should contact Amy Schwartzburg at 415-353-2069.
