health prof v24_Layout 1 28/10/2011 17:12 Page 3
MS: an overview
Types of MS
A multidisciplinary approach to MS care
Relapse and drug therapies
Disease modifying drug therapies
Symptoms, effects and management
Communication and swallowing
Complementary and alternative medicine
Spasticity is one component of the upper motorneurone syndrome9 that occurs as a result of
acquired damage to any part of the CNS,including the spinal cord. It has a range of effects,
Spasticity can be a complex and chal enging
which can be categorised into positive and
symptom to manage in neurological conditions and is
negative features (Table 1). Most people wil
a common symptom experienced by people with
present with a combination of features. One or
multiple sclerosis. The ongoing management of
several of the positive features wil influence the
spasticity requires teamwork between the person with
resistance to passive movement. Often people are
spasticity, their regular carers, and members of the
described as having spasticity, but it is likely they
multidisciplinary team1,2. In a survey 84% of people
wil also have other features of the upper motor
with MS reported symptoms of spasticity with one
third rating it as moderate or severe3.
Table 1. Features of the upper motor neurone
What is spasticity?
The true nature of spasticity is stil not clearlyunderstood. The most common definition used is:
‘a motor disorder characterised by a velocity
dependent increase in tonic stretch reflexes withexaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component
of the upper motor neurone syndrome’4. Moresuccinctly spasticity has been defined as ‘the
velocity dependent increase in resistance of a
More recently these definitions have been
chal enged by a European working group asnarrow and limiting. Specifical y this group
identified that the term spasticity is used differentlyby clinical and research communities and
concluded that spasticity is not a pure motor
disorder, or just a result of the hyper-excitablestretch reflex or dependent on the velocity of the
stretch. They suggested a new definition as,
‘Disordered sensorimotor control, resulting from an upper motor neurone lesion, presenting asintermittent or sustained involuntary activation
Why does spasticity occur?
The control and regulation of normal skeletal muscleactivity involves a complex combination of
The resistance to passive movement caused by
descending motor commands, reflexes and sensory
spasticity is generated by abnormalities in the control
feedback from the brain, spinal cord and peripheral
of movement by the central nervous system (CNS).
sensation. During normal movement, influences from
As wel as this neural involvement of spasticity there
the cerebral cortex, basal ganglia, thalamus and
are also biomechanical changes, which occur both in
cerebel um, travel ing via upper motor neurones
muscles and connective tissue, which through disuse
adjust, reinforce and regulate the lower motor
and immobility can lead to reduced range of
neurone which connects directly via peripheral nerves
movement or contractures7. Increased resistance to
to the muscle to form smooth, coordinated muscle
passive movement felt by the clinician, often referred
activity and maintenance of posture.
to as hypertonia, may be caused by a combination of spasticity, which is neural y generated, and
In simple terms spasticity occurs when there is
biomechanical changes in the muscle and connective
damage to these descending upper motor neurone
tissue. Together these changes can significantly
tracts (eg a plaque in MS) which interrupts the
regulation of spinal cord and lower motor neurone
Multiple Sclerosis Information for Health and Social Care Professionals
activity. This can result in enhanced lower motor
A multidisciplinary approach
neurone activity and an increase in muscle activity,
Effective communication between disciplines is vital
in response to peripheral stimuli (eg muscle stretch,
to enhance the management of an individual’s
a urinary tract infection or pressure ulcer)10,11.
spasticity. Each discipline can be seen to havespecific expertise within the team. However this is
Consequences of spasticity
not exclusive and teamwork is essential1,2.
Spasticity can affect physical activities such aswalking, transferring, picking up objects, washing,
have a significant role in educating a
dressing and sexual activity. It can also have an
person on managing trigger factors and about the
emotional impact, on for example, mood, self-image
available treatments to manage spasticity. They
and motivation12-14. Safety in sitting and lying can also can provide ongoing support and advice to abe compromised due to spasms or persistent poor
person and their family as they live with and adjust
positioning15,16 which can lead to the development of
to managing spasticity and spasms over time.
contractures. This can potential y lead to restrictedmobility and social isolation.
can carry out specific treatments
to assist an individual to manage muscle tone
Symptoms of the upper motor neurone syndrome are particularly the biomechanical changes. Treatment
not always detrimental and they may even be
may include appropriate exercise programmes that
positive in improving vascular flow and assisting in
may encompass stretches, active exercises or
transfers and even walking17. Therefore the treatment
standing. Advice can also be given regarding
of spasticity needs to be careful y selected and
posture and positioning throughout the day.
reviewed over time in order to meet the individual’saims and to maintain and promote function.
can play a key role in
assessing and recommending appropriate
Management and treatment
adaptations to an individual’s environment and
advising on how to maximise activities of daily
Two core principles of spasticity management
living within the context of spasticity. Appropriate
seating is of particular importance in spasticitymanagement.
Optimising an individual’s posture and
through use of appropriate seating,
Occasional y the expertise of speech and language
therapists can be sought when spasticity affectsneck and facial muscles18.
Preventing or managing factors that may
increase spasticity and spasms
Medical management is important in terms of
exacerbations can occur from cutaneous stimuli
assessing, prescribing and evaluating the use of
such as skin irritation, pressure sores, ingrown
antispasticity drugs. In conjunction with other
toenails, tight fitting orthoses. Visceral stimuli
members of the team, doctors can decide the
appropriate timing and selection of more
constipation, bowel impaction and infections, for
example urinary tract infections, can be triggers2, 10.
Patterns of movement in function and sustained
Inpatient rehabilitation may be appropriate to
postures throughout the day and night can also
individual’s spasticity throughout a 24 hour periodand to al ow a more detailed management
These principles need to be regularly considered
and reviewed over time and used in conjunctionwith medical treatments. Pivotal to their success is
Sometimes despite optimal physical management
ongoing multidisciplinary teamwork across hospital
programmes and optimisation of trigger factors
and community settings working col aboratively
pharmacological measures are necessary.
with the person with spasticity to effectively
Depending on the pattern of spasticity these can
MS wil respond to Sativex; whether someone is aresponder can be identified after a four week trial of
acts on the CNS and is the most
the drug. The dose of Sativex is then control ed by
commonly used antispasticity drug. To avoid side
varying the number of sprays taken each day.
effects it needs to be started at low doses, slowlyincreased and stopped at a dose that does not
cause unwanted side effects. The effect of an oralbaclofen dose can last between 4-6 hours so doses
can be injected into muscles and
need to be taken regularly to ensure adequate
acts as a neuromuscular block which causes the
control of symptoms. Side effects can include
targeted muscle to become temporarily weak. It can
take 10-14 days for the ful effect to be felt. It mustbe used in conjunction with physiotherapy/
is useful for treating spasticity
occupational therapy and an exercise programme to
and spasms. It is particularly helpful in managing
maximise effect and to promote an ongoing change
spasticity when pain is associated with it.
in the spasticity once the toxin has worn off (approx.
Side effects can include drowsiness, dizziness
Phenol or alcohol motor point injections
. The injection
The NICE clinical guideline states that the
permanently destroys nerve fibres in the injected muscle.
fol owing should only be given if treatment with
Some nerves may partial y regrow, causing the effect to
baclofen or gabapentin is unsuccessful or side
wear off after several weeks or months. Injections can
also works on the CNS and needs to be
introduced slowly to avoid side effects. Regularblood tests should be performed to ensure there is
acts by binding to gamma
no adverse effect on liver function. Side effects can
aminobutyric acid (GABA) receptors and results in
include weakness, drowsiness and dry mouth.
inhibition of mono and polysynaptic spinal reflexes24with associated reduction in spasm, clonus and pain.
can be used alone or in
A concentration of GABA receptors is situated in the
combination with other drugs. Their daytime use is
intrathecal space of the spinal cord. Delivering
limited by sedative side effects, but if taken prior to
baclofen intrathecal y accentuates its antispasticity
sleep they can be very useful in managing
effect whilst minimising the troublesome systemic
nocturnal spasms. Side effects can include
side effects associated with oral intake.
An implanted pump can deliver baclofen directly to this
is the only antispasmodic drug that
area and can be used to treat generalised lower limb
works directly on the muscles rather than on the
spasticity25-27. It requires commitment from the person
CNS. It can be used in combination with other
with MS, not only during the trial and implant phase,
drugs. Often it is not wel tolerated and can cause
but also for its ongoing maintenance of regular reservoir
nausea, vomiting, diarrhoea and weakness. Regular
refil s and pump replacements2. It is however an
blood tests need to be completed to ensure no
extremely effective treatment and is being used earlier in
people with MS to improve their walking28.
is a cannabis extract which works on the
is a permanent destructive
cannabinoid receptors in the brain and spinal cord.
procedure29. It can be helpful for some people,
It is licensed in MS as an add-on therapy for those
to treat very severe spasms that do not respond
people whose spasticity and spasm has not
to other drug treatments. The effects of an injection can
responded to the other available drugs20, 21. It is
sometimes wear off but can be repeated if necessary.
available as an oral spray. Side effects can includedizziness, sleepiness and feelings of light
Negative effects on lower limb sensation, sexual
headedness. Occasional y the spray can cause
function, bladder and bowel management can occur so
soreness in the mouth so it is important to change
appropriate patient selection is critical to ensure effective
the spray site regularly. About half of people with
strategies are in place to manage these30.
Multiple Sclerosis Information for Health and Social Care Professionals
Intrathecal treatments require a detailed clinical
16. Jarrett L. The role of the nurse in the management of
administration, an example of guidelines and nursing
spasticity. Nurs Residential Care 2004;6(3):116-9.
care plans from one service have been published2.
17. Losseff N, Thompson AJ. The medical management of
increased tone. Physiotherapy 1995;81(8):480-4.
18. Leary S, Jarrett L, Lockley L, et al. Intrathecal baclofen therapy
Occasional y orthopaedic or neurosurgical procedures
improves functional intel igibility of speech in cerebral palsy.
Clin Rehabil 2006;20(3):228-31.
may be recommended. These can include myelotomy
19. Beard S, Hunn A, Wright J. Treatments for spasticity and pain
(severing of tracts in the spinal cord) and rhizotomy
in multiple sclerosis: a systematic review. Health Technol Assess
(resection of posterior roots)31,32.
20. Novotna A, Mares J, Ratcliffe S, et al. A randomized, double
blind, placebo-control ed, paral el-group, enriched-design
Some individuals with spasticity report that
study of nabiximols (Sativex) as add-on therapy, in subjectswith refractory spasticity caused by multiple sclerosis. Eur J
complementary therapies such as acupuncture can
21. Col in C, Ehler E, Waberzinek G, et al. A double-blind
randomized placebo-control ed paral el-group study of Sativexin subjects with symptoms of spasticity due to multiple
sclerosis. Neurol Res 2010;32(5):451-9.
1. Thompson AJ, Jarrett L, Lockley L, et al. Clinical management of
22. Turner-Stokes L, Ashford S. Serial injections of botulinum toxin
spasticity. J Neurol Neurosurg Psychiatry 2005;76(4):459-63.
for muscle imbalance due to regional spasticity in the upper
2. Stevenson VL, Jarrett L. Spasticity management: a practical
limb. Disabil Rehabil 2007;29(23):1806-12.
multidisciplinary guide. Oxford: Informa Health Care; 2006.
23. Royal Col ege of Physicians. Spasticity in adults: management
3. Rizzo, MA, Hadjimichael OC, Preiningerova J, et al. Prevalence
using botulinum toxin. National guidelines. London: RCP; 2009.
and treatment of spasticity reported by multiple sclerosis
24. Davidoff RA, Sears ES. The effects of Lioresal on synaptic
activity in the isolated spinal cord. Neurology
4. Lance JW. Symposium synopsis. In: Feldman RG, Young RR,
Koel a WP, editors. Spasticity, disordered motor control.
25. Penn RD, Savoy SM, Corcos D, et al. Intrathecal baclofen for
Chicago: Year Book Medical Publishers; 1980. p485-94.
severe spinal spasticity. N Engl J Med 1989;320(23):1517-21.
5. Brown P. Pathophysiology of spasticity. J Neurol Neurosurg
26. Porter B. A review of intrathecal baclofen in the management
of spasticity. Br J Nurs 1997;6(5):253-62.
6. Pandyan AD, Gregoric M, Barnes MP, et al. Spasticity: clinical
27. Jarrett L, Leary S, Porter B, et al. Managing spasticity in people
perceptions, neurological realities and meaningful
with multiple sclerosis - a goal-oriented approach to intrathecal
measurement. Disabil Rehabil 2005;27(1/2):2-6.
baclofen therapy. Int J MS Care 2001;3(4):10-21.
7. Carr J, Shepherd R. The upper motor neurone syndrome. In:
28. Erwin A, Gudesblatt M, Bethoux F, et al. Intrathecal baclofen in
Neurological rehabilitation: optimizing motor performance.
multiple sclerosis: too little, too late? Mult Scler 2011:17(5):623-9.
Oxford: Butterworth-Heinemann; 1998. p85-203.
29. Bonica JJ. Neurolytic blockade and hypophysectomy. In: Bonica
8. Dietz V. Spastic movement disorder: what is the impact of
JJ. The management of pain. 2nd edition. Philadelphia: Lea &
research on clinical practice? J Neurol Neurosurg Psychiatry
30. Jarrett L, Nandi P, Thompson AJ. Managing severe lower limb
9. Greenwood R. Introduction: spasticity and upper motor
spasticity in multiple sclerosis: does intrathecal phenol have a
neurone syndrome. In: Sheean G, editor. Spasticity
role? J Neurol Neurosurg Psychiatry 2002;73(6):705-9.
rehabilitation. London: Churchil Communications; 1998.
31. Lazorthes Y, Sol JC, Sal erin B, et al. The surgical management
10. Sheean G. Neurophysiology of upper motor neurone
of spasticity. Eur J Neurol 2002;9(Suppl 1):35-41.
syndrome and spasticity. In: Barnes MP, Johnson GR, editors.
32. Mittal S, Farmer JP, Al-Atassi B, et al. Long-term functional
Upper motor neurone syndrome and spasticity: clinical
outcome after selective posterior rhizotomy. J Neurosurg
management and neurophysiology. Cambridge: Cambridge
11. Stevenson VL, Marsden JF. What is spasticity? In: Stevenson V,
Jarrett L, editors. Spasticity management: a practicalmultidisciplinary guide. Oxford: Informa Health Care; 2006. p3-14.
12. Ward N. Spasticity in multiple sclerosis. J Community Nursing
MS Trust resources
13. Porter B. Nursing management of spasticity. Primary Health
14. Currie R. Spasticity: a common symptom of multiple sclerosis.
15. Keenan L, Stevenson V, Jarrett L. Care Pathway: The role of the
health care professional in the management of spasticity.
health prof v24_Layout 1 28/10/2011 17:13 Page 93
Multiple Sclerosis Information for Health and Social Care Professionals
We hope you find the information in this book helpful. If you would like to speak with someone about anyaspect of MS, contact the MS Trust information team and they wil help find answers to your questions.
This book has been provided free by the Multiple Sclerosis Trust, a smal UK charity which works toimprove the lives of people affected by MS. We rely on donations, fundraising and gifts in wil s to be ableto fund our services and are extremely grateful for every donation received, no matter what size.
MS Trust information service
Helping you find the information you need
The MS Trust offers a wide range of publications, including a newsletter forhealth and social care professionals Way Ahead and the MS InformationUpdate, which provides an ongoing update on research and developments inMS management.
For a ful list of MS Trust publications, to sign up for Way Ahead
and much more visit our website at www.mstrust.org.uk
0800 032 3839 (Lines are open Monday - Friday 9am-5pm)
MS TrustSpirel a BuildingLetchworth Garden CitySG6 4ET
This publication wil be reviewed in three years
MS Trust Multiple sclerosis information for health and social care professionals. Fourth edition.
ISBN 1-904 156-24-X 2011 Multiple Sclerosis Trust
Al rights reserved. No part of this book may be produced, stored in a retrieval system or transmitted in any form by any means,electronic, electrostatic, magnetic tape, mechanical, photocopying, recording or otherwise without written permission of the publisher.
Common Assessment Framework Introduction Northwards Housing has a comprehensive Safeguarding Children Policy and Procedure which was written and approved in March 2008. This policy is refreshed annually and fully reviewed every three years. It is also important to note that it is kept under continuous review in light of local and national developments. Northwards Housing recognises t
Mise en scène : Eric De Staercke Avec Bruno Coppens Pierre Poucet Compositions musicales : Eloi Baudimont Régie, éclairages et son : Benoît Lavalard Assistant à la mise en scène : Gael Soudron Costumes : Lili Deconinck Professeur de chant : Aïssatou Diop Construction décor : Marc Cocozza, Mathieu Regaert et Quentin Huwaert Peinture décor : Pauline Picry U