Spasticity In Multiple Sclerosis

The use of a recently released AntiConvulsant, Gabapentin, in the treatment of Spasticity in two patients with Multiple Sclerosis is reported.

Gabapentin was chosen because of its GABA-ergic effect and because previously reported studies have shown that it is well tolerated compared with other GABA-mimetic medication.

Satisfactory release of Spasticity with significant improvement of functional outcome was noted in both cases. Both patients were first treated with Gabapentin for one month at 300 mg per day and then, with no reported side-effects, at 400 mg per day.

Before treatment, Spasticity (graded with modified Ashworth Scale) in one patient was 3 for left lower and 2 for right lower limbs, and Expanded Disability Status Scale (EDSS) was 7; ambulation was limited to a few steps with a standard walker.

After two weeks of treatment, Spasticity was 2 and 1 for the left and right lower limbs, respectively.

At three-month intervals, Spasticity was +1 for left and 1 for right lower limbs, and EDSS was 6; the patient could ambulate 75 to 100 m with a standard walker.

In the second patient, Spasticity before treatment was 2 for both lower and left upper limbs. EDSS was 5.5, and ambulation was confined to 100 m with a cane.

Spasticity improved to +1 in lower and 1 in left upper limbs after two weeks and to 1 and normal after three months. At three months, EDSS was 3 and the patient could ambulate for long distances without an assistive device.

We suggest that Gabapentin can be used effectively to decrease Spasticity without significant side effects in patients with Multiple Sclerosis.

Thirty men and women diagnosed with definite Multiple Sclerosis (MS) were treated for ten weeks in a blinded, cross-over study.

Patients with minimal to moderate Spasticity were randomized to one of three sequences to evaluate the effects on MS-related Spasticity of Baclofen alone, stretching regimen with placebo, placebo alone, and stretching regimen with Baclofen.

The Cybex II Isokinetic Unit, Timed Gait, Ashworth Scale, and subject's assessment of function were objective and subjective measures used to evaluate changes in HyperTonicity. There was significant correlation between the Cybex and Ashworth as methods of measuring Spasticity.

Overall, treatment with Baclofen alone significantly improved moderate quadriceps Spasticity as measured by Cybex flexion scores. A trend, indicative of enhancing the beneficial effects of Baclofen, was noted when stretching exercises were added to the treatment.

Baclofen was used in a double-blind crossover placebo-controlled trial to treat Spasticity in patients with Multiple Sclerosis (MS).

While on Baclofen, patients obtained a significant (p less than 0.001) reduction in Spasticity compared to controls.

The drug was particularly effective in alleviating Flexor and Extensors Spasms, as well as their associated Pain. Side effects were common in this study, but were usually well tolerated by the patients.

The commonest side effects were sedation, nausea and vomiting. There were no changes in Hepatic, Renal, or Hematological function in any patients. Increase Weakness due to loss of Spasticity for support was also a fairly common complaint.

The drug seems best indicated in patients in whom Spasticity is not required for support or other activities of daily living. Careful monitoring of the patient is essential for effective use of this drug.

Baclofen is a safe and effective means for treating Spasticity associated with Multiple Sclerosis. We found no toxic effects on Hepatologic, Hematopoietic, or Renal Function, acutely or for over 3 years of follow-up.

A statistically significant reduction was noted in frequency of Spasms, and Clonus, and there was improved range of joint movement, which enabled patients to maintain functional status for prolonged periods.

For the more disabled patients, treatment with Baclofen gave symptomatic relief of painful Spasms and made immobility more tolerable.

Optimum effect was achieved when Baclofen was administered in the early stages of disease, before major disabilities became permanent.

A double-blind, five-week, multicenter trial was conducted to compare the effect of Baclofen, a unique Amino Acid derivative, with that of placebo in the treatment of 106 patients with Spasticity secondary to Multiple Sclerosis.

A Spasticity assessment method that included a Neurological Examination, physicians' clinical impressions of changes during treatment, and a patient's self-evaluation was used to determine efficacy.

This method showed Baclofen (70 to 80 mg daily maximum, titrated) is effective relative to placebo in relieving symptoms of Spasticity, such as flexor spasms, pain and stiffness, resistance to passive joint movements, and tendon stretch reflexes.

Patient self-evaluation results also showed a significant reduction in Clonus. Side effects were generally mild and transient.

We studied the effect of Botulinum-A toxin on Spasticity of the leg Adductors in 9 patients who were either chair-bound or bed-bound with Chronic stable Multiple Sclerosis.

We injected Botulinum Toxin (400 mouse units) or placebo into the Adductor Muscles in a randomized, crossover, double-blind design.

Two physicians, who were unaware of the treatment order, used an objective rating scale and independently assessed the patients; interobserver correlation was excellent (r = 0.93-0.81).

We found that Botulinum Toxin produced a significant reduction in Spasticity (p = 0.009) and a significant improvement in the ease of nursing care (p = 0.009).

There were no adverse effects during this short-term trial. This is the first demonstration of the beneficial effect of Botulinum Toxin on focal Spastic muscle contractions.

• Comment in: Ann Neurol 1992 Jan;31(1):113

Spasticity is a velocity-dependent pathologic increase in muscle resistance to stretch, and occurs in a variety of Neurologic Disorders.

We report our controlled open study using Botulinum Toxin A for treatment of Adductor Spasticity in five patients with advanced Multiple Sclerosis. Clinical evaluation of Spasticity and stiffness of joints is based on the Ashworth Scale and grade of passive Abduction.

Three patients showed no response; the two others experienced an excellent and longlasting effect. We also describe briefly the different Spastic conditions where this treatment has been used successfully.

Objective
To explore the range of functional indications and benefit of Botulinum Toxin A (BTA) in Spastic patients.

Design & Setting
Case report of a series of patients selected for BTA treatment. Clinical information was collected in a prospective fashion on each patient. Freestanding acute rehabilitation hospital.

Patients & Intervention
39 consecutive patients with 40 limbs with acquired Spasticity. All 39 patients received BTA injections into muscles targeted for treatment based on functional indications.

Main Outcome Measures
Objective evaluation of outcome was measured by Ashworth Scale, Goniometry, Ambulation Score, and Brace Wear Scale. Subjective measures included patient self report of improvement and pain relief.

Results
Mean BTA dose per limb was 180 units, mean number of muscles injected per limb was 2. Twenty-nine patients had subjective and/or objective improvement with treatment.

Mean Ashworth Scale improvement was one point. Mean gain in Active Range Of Motion (AROM) was 17.0 degrees, and in Passive Range Of Motion (PROM) 18.4 degrees.

Brace tolerance improved in 14 of 22 patients and pain relief occurred in 10 of 13 patients. There were no adverse effects, and there was no difference in duration of effect compared to Dystonia patients.

Conclusion
BTA is a useful intervention in the treatment of Spasticity, with the majority of patients demonstrating improvement on objective measures of tone and function, and reporting improvement on subjective measures. Careful patient selection will maximize functional benefit.

• Comment in: Arch Phys Med Rehabil 1997 Feb;78(2):233-4