What treatment options are available for a patient with Multiple Sclerosis (MS) experiencing progressive weakness and muscle spasms, resulting in frequent falls?

From the Guidelines

For a patient with MS experiencing progressive weakness and muscle spasms, resulting in frequent falls, the most effective treatment approach is a multidisciplinary one, incorporating occupational therapy (OT) and physical therapy (PT) to prevent falls and improve function, as well as the use of orthotics and assistive devices such as canes and walkers. This approach is supported by recent guidelines, including a 2023 study published in Ca-A Cancer Journal for Clinicians 1, which emphasizes the importance of early intervention and prevention of severe joint contractures and deconditioning, restoration of range of motion, strength, mobility, and pain relief.

Key components of this treatment plan include:

• OT and PT to improve mobility, strength, and function, and to prevent falls 1
• Orthotics and assistive devices, such as canes and walkers, to improve stability and prevent falls 1
• Bracing and splinting to support joints and prevent contractures 1
• A walking program, resistance training, and core strengthening to improve muscle strength and mobility 1
• Management of fatigue and musculoskeletal symptoms through gradually increasing exercise regimens, activity pacing, cognitive behavioral strategies, and sometimes medication 1

While the provided evidence is focused on rehabilitation among children with cancer, the principles of early intervention, prevention of complications, and multidisciplinary treatment approaches can be applied to patients with MS experiencing progressive weakness and muscle spasms. The use of medications such as baclofen, tizanidine, or diazepam may also be considered to reduce muscle tone and alleviate spasticity, but should be individualized based on symptom severity, medication tolerability, and functional goals, with regular follow-up to adjust therapy as needed.

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. Tizanidine’s capacity to reduce increased muscle tone associated with spasticity was demonstrated in two adequate and well controlled studies in patients with multiple sclerosis or spinal cord injury.

Treatment options for a patient with Multiple Sclerosis (MS) experiencing progressive weakness and muscle spasms, resulting in frequent falls, include:

• Baclofen (PO): 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 2
• Tizanidine (PO): to reduce increased muscle tone associated with spasticity in patients with multiple sclerosis 3

From the Research

Treatment Options for Multiple Sclerosis (MS)

• Treatment with botulinum toxin can provide an efficient and safe alleviation of spasticity and related problems in MS patients, given a realistic definition of the therapeutic target and a graded multimodal approach 4.
• Rehabilitation treatment, including professional rehabilitation and new technologies such as transcranial magnetic stimulation and virtual reality, can reduce functional dysfunction, improve neurological function, and reduce family and social burdens in MS patients 5.
• Oral agents such as tizanidine and baclofen can be used to treat spasticity in MS patients, with tizanidine producing an apparent improvement of mobility in some patients with moderate or marked paresis associated with marked spasticity of their legs 6.
• A multifactorial approach to fall prevention is likely needed, including exercise-based interventions, education, and consideration of physiological, personal, and environmental factors 7.
• Treatment strategies for spasticity management in MS include skilled rehabilitation strategies, neuromuscular blocks, oral agents, intrathecal management, and surgery, with rehabilitation strategies being central and other strategies added based on the level of impairment and functional loss 8.

Management of Spasticity and Falls

• Spasticity can result in significant medical complications and is associated with increased disability in MS patients, making treatment essential for their health, functional status, and well-being 8.
• Falls are highly prevalent in people with MS and result in a range of negative consequences, such as injury, activity curtailment, and reduced quality of life, highlighting the need for effective fall prevention strategies 7.
• Providers must use well-developed clinical skills to arrive at optimal individualized treatment programs and monitor them frequently, considering the numerous secondary impairments in MS and its associated polypharmacy 8.