More MS news articles for August 2002

Narcoms Report - The Experience of Spasticity Among Registry Participants

http://www.epva.org/MSQR_Archive/Spring02_4.htm

MSQR - V21.  N1.   Spring  2002
Olympia Hadjimichael, MPH, Coordinator, NARCOMS Project, Yale Multiple Sclerosis Research Center, Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT

As Dr. Schapiro reports in his article in this issue, most persons with multiple sclerosis (MS) are hindered not only by fatigue and muscle weakness but also by spasticity, which causes pain and difficulty in movement. The NARCOMS Registry provides a unique opportunity to study the prevalence of spasticity within a large MS population. In this report we will examine the levels of spasticity that were reported by the Registry participants in the May and November 2001 Update Questionnaires as well as management of their symptoms.

Registry data show that spasticity is a common experience among persons suffering with MS. Only 16.4% of all registrants do not experience any symptoms of spasticity. Of the rest, 50% report minimum to mild, 25.6% moderate, and 18% severe to total disability due to spasticity.

Table 1 highlights the characteristics of registrants who report higher spasticity levels (moderate to severe and total disability due to spasticity) compared to those with lower levels. Those who report higher levels of spasticity are more likely to be male and older. The more pronounced the experience of spasticity, the more likely it is that registrants will be disabled and unemployed. Consequently, most of them are in the Medicare/Medicaid health care system and significantly fewer have private insurance.

The MS-related disease characteristics of those who have higher levels of spasticity are shown in Table 2. They are more likely to have MS for a longer period of time, to report relapses in the last 6 months, and have their symptoms worsen over the last 6 months. Overall, the higher the level of spasticity experienced, the lower the level of quality of life reported as indicated by the Physical Health score of the SF-12 scale.

Spasticity is experienced more frequently by registrants with relapsing worsening type of MS, as seen in Figure 1. Those who report moderate, or severe and total spasticity have mostly relapsing worsening MS and those with severe, and total spasticity levels are twice as likely to have worsening rather than stable MS (56% vs. 28%). Primary progressive MS is not associated with high levels of spasticity.
 

Table 1. Demographic Characteristics of Registrants With Spasticity
 
Spasticity Levels
 
None
Minimal–Mild
Moderate
Severe–Total
 
N = 3,077
N = 9,366
N = 2,921
N = 3,363
 
 
 
 
 
Male (%)
17
23
27
31
 
 
 
 
 
Mean Age (SD)*
43.7 (11.0)
46.7 (10.7)
48.0 (10.2)
48.5 (9.9)
 
 
 
 
 
Employment (%)        
  Employed
63.9
47.0
27.4
15.8
  Disabled
14.0
31.0
52.5
63.7
 
 
 
 
 
Insurance (%)
 
 
 
 
  Medicare
5.8
8.9
14.1
14.8
  Medicaid/Medicare
10.5
20.4
30.5
39.0
  Private/Commercial
78.5
63.6
47.4
36.7
*SD = Standard Deviation        
Table 2. Disease Characteristics by Spasticity Level 
 

Spasticity Levels

  None
Minimal–Mild
Moderate

Severe–Total

Mean Duration of Disease 
8.8
11.0
11.8
13.4
Mean Length of Symptoms 
14.1
17.9
19.5
20.1
         
Relapse in Past 6 Months (%)
17.2
22.9
30.4
27.1
Symptoms Change in Past 6 months (%)
 
 
 
 
    Worse
19.3
34.7
45.8
45.8
    No change
37.6
25.5
15.2
10.6
    Better 
12.3
  9.2
  5.8
  2.9
 
 
 
 
 
Quality of Life Score (SF-12)*
 
 
 
 
    Physical Health Score
48.0
39.8
33.3
28.5
    Mental Health Score
52.1
51.2
48.3
46.6

* A two-page questionnaire that participants completed in the May 2001 Update. It measures how a respondent feels and how well he or she is able to do usual activities.

Table 3. Mean Disability Score by Spasticity Level
 
None
Minimal–Mild
Moderate
Severe–Total
PDDS * 
1.6 
3.4 
4.7 
5.7 
Performance Scales 
 
 
 
 
  Mobility
1.1
2.6 
3.7 
4.7 
  Hand
0.8 
1.4 
2.2 
3.0 
  Cognitive
1.1 
1.5 
2.0
2.1 
  Vision
1.0 
1.3 
1.7 
2.0 
  Fatigue
1.8 
2.6 
3.3 
3.7 
  Bladder/Bowel
1.0 
1.7 
2.4 
3.1 
  Sensory
1.0 
1.6 
2.5 
3.1 
  Pain
0.8 
1.5 
2.3 
2.7 
  Tremor
0.7
1.5 
2.4 
3.1 
  Depression
0.9 
1.2 
1.7 
1.9 

*PDDS (Patient Determined Disease Steps) measures disability based primarily on mobility

Table 4. Medication Use by Registrants With Spasticity
 
Spasticity Levels
 
None
Minimal–Mild
Moderate
Severe–Total
 
%
%
%
%
 Immunologic Therapies
58.9
60.8
57.0
50.6
 Alternative Therapies
18.8
18.2
18.2
18.6
 Symptomatic Drugs
42.7
65.0
79.5
82.3
 
 
 
 
 
 Any one Drug for Spasticity
14.1
27.8
35.9
34.3
 Two or More Spasticity Drugs
4.2
14.4
27.5
36.9
        Amitriptyline (Elavil®)
5.4
7.9
10.5
9.9
        Lioresal® (Baclofen)
4.2
22.3
37.7
46.1
        Clonazepam (Klonopin®)
3.1
5.7
9.0
10.4
        Diazepam (Valium®)
3.0
6.1
11.5
14.1
        Tizanidine (Zanaflex®)
1.2
7.8
16.4
23.1
        Gabapentin (Neurontin®)
6.5
10.5
14.4
16.7
        Botulinum (Botox®)
0.1
0.2
0.2
0.9
        Intrathecal Baclofen Pump®
0.2
0.7
1.7
2.5

Higher levels of spasticity are associated with increasing levels of disability (Figure 2). This is also reflected in the mean Patient Determined Disease Steps (PDDS) score in Table 3. Those who have more physical disability are more likely to have increased spasticity. Similarly, the mean scores of the other neurological functions (measured by the Performance Scales) show increasing spasticity with increasing MS severity. The strongest correlations are with mobility, hand function, sensory ability, and tremor.

In addition to immunologic therapies used to alter the course of the disease, registrants use a number of drugs to minimize spasticity. Table 4 shows the reported use of therapies and symptomatic drugs and the most frequently used drugs for spasticity. Registrants with higher levels of spasticity make increasing use of symptomatic drugs and specific use of drugs for spasticity. The most frequently used are baclofen, tizanidine, and Neurontin®. A significant number of registrants with high spasticity take a combination of more than one of these drugs (36.9%) in order to achieve adequate relief.

Registry data show that the experience of spasticity is related to disability due to MS. It is mostly present among those who have high disability and it causes additional difficulties to the patient on its own. Spasticity contributes to being incapacitated and unemployed, and it diminishes the quality of life of those who endure it. A large number of medications are available to alleviate the symptoms, and combinations of more than one drug may have increased effectiveness for those registrants who have severe forms of spasticity. However, our data suggest that more effective therapies for spasticity could substantially improve the lives of many patients with MS.

Figure 1: Spasticity Levels by Type of MS

Figure 2. Average Spasticity Score at Each Level of Disability.


Patient Determined Disease Steps (PDDS)

*SD = Standard Deviation
 

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