Spasticity in MS: Integrating Rehab and Medical Treatments

This transcript has been edited for clarity. 

Francois Bethoux, MD: Hello. My name is Francois Bethoux. I'm a physical medicine and rehabilitation physician at the Cleveland Clinic here in Cleveland, Ohio. I am joined by Patty Bobryk.

Patricia Bobryk, MHS, PT, MSCS, ATP: Thank you, Dr Bethoux. My name is Patty Bobryk. I'm a physical therapist. I work at Yampa Valley Medical Center, which is part of UC Health, in beautiful Steamboat Springs, Colorado.

Bethoux: Our goal here is to discuss the management of spasticity in individuals with multiple sclerosis (MS). Spasticity affects people with many conditions, but we both think that, in MS, there are specific features that make the management of this symptom, maybe, a little more complex and certainly that warrant multidisciplinary care.

I wanted to get started by sharing my thoughts as a physician. When a patient comes into my clinic, complaining of spasticity, I want to pay attention to spasticity, of course, as a symptom, but also as a movement disorder. 

Actually, spasticity affects movement in two ways. It can cause less movement or more difficult movement, like difficulty moving a muscle because everything stiffens up when a person tries to move. It can also cause extra movements. We call them spasms or clonus. That can also interfere with function because the spasms may happen at odd times or at times when somebody is trying to stand and walk, for example, or to use their arm and hand.

The other part that is very important to me is to consider the interaction between spasticity and other symptoms of MS. To give a concrete example, most people who have spasticity also have weakness. They may come to us and say, “Well, my legs don't want to move. They're very stiff.” 

Then, when we do an exam, we realize that their legs don't move very well, both because there's weakness in the muscles and because the muscles stiffen up. That's very important to know before we draft a treatment plan. We want that treatment plan to be very goal-oriented. For spasticity, I think it's very important. 

For example, I'm always asking myself, are we trying to improve the person's comfort, level of pain, or ability to sleep peacefully because their sleep right now is disrupted by spasms? Are we trying to promote ease of care for somebody who needs help from others for their self-care? 

Are we looking to improve posture, position, or to avoid abnormal pressure points that could lead to pressure injury, which is a very regrettable complication when people have low mobility? Are we trying to improve active function, walking, and the ability to use the upper limbs as well? 

It's very important to bring the patients on board and also their family or caregivers to understand what goals would be achievable and then to explain how the treatment may help achieve these goals. That's really where I start. 

I have to say that I consider that spasticity doesn't always need to be treated. Particularly, spasticity doesn't always need to be treated with medication. I always try rehabilitation first when managing spasticity. 

If it's okay with you, Patty, I would hand it off to you to explain how a physical therapist would approach the management of spasticity. 

Rehabilitation Therapy for Spasticity: What Are the Options?

Bobryk: Absolutely. Thank you, Dr Bethoux. I appreciate the collaboration between the medical team and the rehab team. I think that's really a key point when we're addressing spasticity in our patients.

I am a nonpharmaceutical, symptom-management strategy person. Our evaluation in rehab is really key to addressing those key pinpoints in spasticity management. I agree with you 100% that not all spasticity needs to be treated, particularly if patients are relying on spasticity as a means for their mobility. Often times, people use their extensor spasticity to stand, to perform a transfer, or to get up from the commode so that their clothing can be pulled up.

Knowing exactly for what function the patient uses that spasticity is key in the overall management, because just because we see it, we don't have to treat it. Good evaluation is absolutely imperative. 

Good communication between the rehab team and the medical team is also important when spasticity isn't being well managed, for instance in cases where our rehab interventions are not as effective as we hope them to be. Patients might be on a pharmaceutical agent, but still their spasticity might not be well managed. 

Like you said, it interferes with their sleep, with their hygiene, with their mobility, and with their safety because they may be at higher risk of falling because of their spasticity. That communication between the rehab team and the medical team to select next steps is really best to help achieve better outcomes for our patients.

There are some things, from a rehab standpoint, that we can do, of a nonpharmaceutical nature. Exercise, stretching, strengthening, and balance retraining have evidence for reduction in spasticity. 

Also, we have some modalities that are effective in spasticity management. Things like electrical stimulation, electrical stimulation coupled with cycling, aerobic training, like over treadmill training, or a walking program are ways to manage spasticity well. 

There are other things that are less common and aren't always available in all our clinics. Transcranial magnetic stimulation has been found to be a spasticity reducer. What I'm saying, too, is that this collaboration and the combination of nonpharmaceutical interventions with pharmaceutical interventions are key.

I think the role for rehab, too, in some other areas, that crossover to you, Dr Bethoux, is in the role of botulinum toxin (Botox) intervention in a spasticity clinic. Being able to have a good physical therapy or occupational therapy evaluation and being able to identify those key muscles that we might target with our Botox is really imperative for better outcomes. 

Having said that, I'll kick that over to you, Dr Bethoux, to ask what other things you want to add as far as the medical management of spasticity. 

Combining Pharmacological Treatment with Rehab

Bethoux: Thank you, Patty. I would complement what you’re saying by stressing the synergies between different providers to pursue the patient's goals and try to maximize outcomes. As you said, I actually often get referrals from physical and occupational therapists saying, “I'm hitting a plateau in the progress that the patient is making, and I think these stiff muscles are really getting in the way.” That's where we could have a targeted approach. 

The pharmacological approaches to treating spasticity are not infinite, but the number of interventions is increasing. There are pills or oral medications that we can use when we seek a more global relaxation of the muscles. Then we have more focal treatments like Botox injections that can provide very targeted relaxation, because we don't always need to relax many muscles at the same time, and we may also be wary of some of the side effects of oral medications. 

Personally and anecdotally, I’ve found that, among all of my patients who have spasticity, those with MS seem to be particularly sensitive to the side effects from oral medications for spasticity, like baclofen, tizanidine, dantrolene, such as sedation, drowsiness, dizziness, and also weakness, all of which could, as you said, backfire as treatment by actually decreasing function instead of increasing function, as we would be seeking.

A more local treatment is less likely to cause this type of complication. It often takes a village to treat symptoms of MS, including spasticity. There are also more potent treatments like intrathecal baclofen therapy. These treatments are very potent and decrease spasticity in a large number of muscles.

Intrathecal baclofen mostly affects the lower extremities and could also have some effects on the upper body to a lesser degree. It is really more indicated in spasticity that is severe or has severe consequences. For me, the decision to go for intrathecal baclofen is always made in conjunction with input from our physical therapists because there's a surgery involved, and we want to be mindful of the risk-to-benefit ratio there. 

I also want to point out that self-management, as part of all MS management, is very important. I think we both try to get our patients and their caregivers to do some stretching every day. Even though stretching will not make spasticity go away, it goes a long way in maintaining the range of motion. 

Some kind of exercise routine will benefit at many levels, right? There will be a benefit for spasticity, but also strength, cardiovascular, respiratory status, and overall fitness. That is important. It's a holistic approach where, yes, we want to target a symptom like spasticity, but we really want to build synergies and benefit the patient's overall health and well-being.

I would kick it back to you to tell me how you see that overall management should be conducted to the greatest benefit of our patients. 

Bobryk: I would like to circle back to something key that we sometimes overlook in spasticity management and that is the self-management that you mentioned before.

I think that a little bit of education goes a long way in empowering the patient and their family caregivers. Education on how to manage their spasticity is really integral in getting the best results. We should be educating them about what might be triggers for their spasticity. Are they heat sensitive, and their spasticity increases then? Other considerations include wearing tight clothing and looking for an infection if their spasticity increases. 

I always think of spasticity as a moving target, and that there are many things that can influence it. Giving some knowledge to the patient and family so that they are able to do things on their own that will make them either more comfortable or more functional is key.

As you say, I think that “it takes a village,” that the comprehensive model is key in not only the management of spasticity but also in managing many of the other symptoms of MS. Working with the entire healthcare team in a collaborative way gives us our best outcomes. 

Thank you, Dr Bethoux. 

Bethoux: Thank you very much.