From the Guidelines
For severe bilateral hand contractures in a multiple sclerosis (MS) patient, a multidisciplinary approach combining physical therapy, medication, and possibly interventional procedures is recommended, prioritizing the reduction of spasticity and improvement of hand function to minimize morbidity, mortality, and enhance quality of life. Physical therapy should be initiated promptly with daily passive and active range-of-motion exercises, focusing on stretching the affected muscles for 15-20 minutes, 2-3 times daily, as supported by the American Heart Association/American Stroke Association guidelines 1.
Key Components of Management
- Splinting may be beneficial, with resting hand splints worn at night and dynamic splints during portions of the day, to prevent further contracture development, as suggested by the guidelines for adult stroke rehabilitation and recovery 1.
- Medication options include baclofen (starting at 5mg three times daily, gradually increasing to 20mg three times daily as tolerated), tizanidine (2-4mg three times daily), or diazepam (2-5mg twice daily) to reduce spasticity.
- For focal contractures, botulinum toxin injections (typically 100-400 units total, divided among affected muscles) can provide 3-4 months of relief.
- Heat therapy before stretching and regular massage can improve tissue pliability.
- In severe cases unresponsive to conservative measures, surgical interventions like tendon releases may be considered, as indicated by the guidelines for the management of systemic sclerosis 1.
Rationale
These contractures occur due to prolonged spasticity causing muscle shortening and fibrotic changes in connective tissues, which is common in MS due to upper motor neuron damage. Early intervention is crucial as established contractures become increasingly difficult to reverse over time. The EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis also support the consideration of patient education, self-management support, and various exercises for improving hand function and quality of life 1. However, the most recent and highest quality evidence should guide the management approach, prioritizing interventions that directly address spasticity and contracture prevention.
From the FDA Drug Label
Baclofen tablets are useful for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity. The answer to the question of treating severe bilateral hands contracture in an MS patient is that baclofen may be useful for alleviating signs and symptoms of spasticity resulting from multiple sclerosis. However, the label does not directly address severe bilateral hands contracture.
- The primary use of baclofen is for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity.
- Baclofen treatment is intended for patients with reversible spasticity to aid in restoring residual function 2, 3.
From the Research
Treatment Options for Spasticity in MS Patients
- Oral antispasticity medications are useful in managing mild spasticity, but are frequently ineffective in controlling moderate to severe spasticity 4
- Intrathecal baclofen (ITB) therapy can be an effective alternative to oral medications in patients who have a suboptimal response to oral medications or who cannot tolerate dose escalation or multidrug oral regimens 4, 5, 6, 7
- Other options for spasticity management include therapeutic exercise, physical modalities, complementary/alternative medicine interventions, chemodenervation, and implantation of an intrathecal baclofen pump 5
- Botulinum toxin and local application of alcohol or phenol can also be used to treat spasticity, depending on the local or diffuse nature of the spasticity and its etiology 8
Efficacy of Intrathecal Baclofen in MS Patients
- ITB therapy has been shown to provide effective long-term treatment of spasticity in MS patients, with significant improvements in spasticity, disability, pain, and spasm frequency 6, 7
- ITB therapy can also improve quality of life and functional independence in appropriately selected cases 6, 7
- The average 1-year dose of ITB in MS patients has been reported to be substantially lower than in patients with central or spinal origins of spasticity 7