Jodie K. Haselkorn, MD, MPH, gave a brief overview of the updated clinical practice guidelines for spasticity management in multiple sclerosis (MS) during a recent teleconference held by the Consortium of Multiple Sclerosis Centers. Dr. Haselkorn, Director of the MS Center of Excellence West in Seattle, spearheaded the effort to develop the guidelines in 2003 and was also involved in updating them in the subsequent two years.

INCREASED AND IMPROVED OPTIONS

"I remember the days when the only treatments we had available were range-of-motion exercises, diazepam, dantrolene, and baclofen," remarked Dr. Haselkorn. "I’m really delighted and enthused that today my impressions are so much more hopeful due to the increased and improved options that we have available. We have nonpharmaceutical options, oral medications, neuromuscular blockade, and intrathecal therapy that can really help us manage spasticity." Dr. Haselkorn is also an Associate Professor of Rehabilitation Medicine and an Adjunct Associate Professor of Epidemiology at the University of Washington School of Public Health and Community Medicine in Seattle. The updated guidelines were published in 2005 in the Journal of Spinal Cord Medicine.

WHAT HASN’T CHANGED

Since the guidelines were originally developed, a very significant number of patients still have functional consequences due to spasticity, said Dr. Haselkorn. She estimated that about 60% of patients with MS will have problems due to spasticity that limit their function. "What really hasn’t changed is that we have to ask the individual how he or she is doing. You have to really be explicit about [whether the patient is] having problems with spasticity, spasm, heaviness, tucking, and so on."

She also pointed out that it is important for clinicians to believe patients’ reports about symptoms, because "what you see in the office may not be their 24/7 experience. It’s often the case that people, particularly those that are sitting in wheelchairs with flexed knees and flexed hips, aren’t perhaps as spastic in the clinic as they are at home when they lie down to go to bed," she explained.

Dr. Haselkorn urged physicians to identify what triggers spasticity, especially in patients with a new onset of or a change in spasticity. Clinicians should "carefully explore the noxious stimuli that [patients] might be having, stressors, whether their disease has changed, or whether there is some underlying new condition," she advised.

Dr. Haselkorn also pointed out the need to identify patients’ functional limitations. This is important, she noted, "because those limitations are going to be our targets to monitor the success of therapy. We can monitor that success through visual analog types of instruments or through the use of modified Ashworth scores, spasm frequency, pain intensity, range of motion, and so on."

Additionally, Dr. Haselkorn emphasized the importance of assessing patients’ individual preferences. "The most effective management is one that someone is going to be able to follow, and follow long term," she said.

WHAT’S NEW

"I think what’s new and what’s great, encouraging, and exciting is we really have seen interest and development from both the pharmaceutical industry and the device manufacturers, and we have new treatments that are being developed almost every day," said Dr. Haselkorn.

For example, she said, "in the old guidelines we had a mention of botulinum toxin type A. In the newer guidelines, we mentioned botulinum toxin type B—or mild block." Dr. Haselkorn noted that both botulinum toxin types A and B can be used in combination with alcohol or phenol neurolytic blockade, have observable effects within 12 hours to seven days, and are effective for three to four months. "So we have more options available in terms of neuromuscular blockade for focal spasticity, and that’s terrific," she said. She also suggested that these agents might one day be useful in treating patients with bladder spasticity, as well as for other indications.

Another advance since the original guidelines were published, according to Dr. Haselkorn, is the release of the tizanidine capsule for treating general spasticity. "The tizanidine capsule offers patients who either have difficulty swallowing tablets or need a capsule sprinkled over food another option for getting this oral medication," she said. However, "one of the important things to remember about the capsule is that there are differences in the bioavailability with food." Dr. Haselkorn explained that the plasma bioavailability of the tablet and the capsule is the same when both forms of the drug are taken on an empty stomach; but when taken with food, the capsule has a lower peak plasma concentration and a more sustained effect. "You don’t really see the surge that you would see with tizanidine tablets when you’re taking [the capsules] with food," she said.

Another change in the updated guidelines is that the tables and some text regarding intrathecal therapy have been updated to reflect "increased experience with intrathecal therapy in MS," Dr. Haselkorn commented. "There is a bit more information on test doses and dosing and an updated advantages and disadvantages table that, I think, more truly reflects some of the benefits that many of our patients experience with intrathecal therapy."

WHAT’S NOT INCLUDED

The updated guidelines do not include information about the SynchroMed II pump, Dr. Haselkorn noted. "It has a smaller size, it’s shaped a little bit more nicely, and most important to our patients and to the clinic schedule is that there is a marked reduction in the need to do refills; so instead of an 18-mL reservoir, you can get the new pump in a 40-mL reservoir." According to Dr. Haselkorn, the new pump is advantageous for patients who have mobility problems and prefer not to come in as often for a refill, or for patients who have to make long trips.

NR

—Karen L. Spittler

Suggested Reading
Haselkorn JK, Balsdon Richer C, Fry Welch D, et al. Overview of spasticity management in multiple sclerosis. Evidence-based management strategies for spasticity treatment in multiple sclerosis. J Spinal Cord Med. 2005;28:167-199.

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