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Multiple Sclerosis Management of Motor Symptoms in Multiple Sclerosis Pedro Barros 1,2,3 and Maria José Sá 4,5,6 1. Neurology Resident, Neurology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; 2 & 4. Neurology Resident; Senior Neurologist, Head of MS Clinic, MS Clinic, Centro Hospitalar de São João, Porto, Portugal; 3 & 5. Visiting Professor; Associate and Aggregate Professor of Neurology, Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal; 6. Senior Neurologist, Neurology Department, Centro Hospitalar de São João, Porto, Portugal Abstract Although there has been a significant development, in recent years, regarding disease modifying treatments (DMT) in multiple sclerosis (MS), there is a continuous need to manage the wide range of symptoms associated with MS. Although surveys vary in their results, mobility is a major concern in MS patients. However, limited evidence exists for symptomatic drug treatment and so it is important to consider all therapeutic options in these patients. Here we review the current evidence in the management of three of the most common and disabling motor symptoms: spasticity, tremor and gait impairment. Keywords Deep brain stimulation, gait, multiple sclerosis, spasticity, tremor Disclosure: The authors have no conflicts of interest to declare. Received: 16 May 2013 Accepted: 21 June 2013 Citation: European Neurological Review, 2013;8(2):124–9 Correspondence: Pedro Barros, Department of Neurology, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502, Vila Nova Gaia, Portugal. E: Although disease modifying treatments (DMT) have been available for multiple sclerosis (MS) for many years, there is a continuous need to manage the variety of symptoms reported by the patients and to lessen the accumulation of impairments and disability that accompany disease progression. Symptomatic treatment, an important arm in the whole management of MS, is classically divided into pharmacological and non-pharmacological methods, the former relying on medications that are usually not specific for patients with MS. To treat the wide range of symptoms associated with MS can be frustrating, given that available drug treatment is limited in its efficacy. MS symptoms that interfere with daily life may be rather disabling, mobility is a major concern, which usually results from a range of motor disturbances. In its turn, the impairment of motor functions is common and correlate with poorer prognosis. 1 Here we review the current evidence in the management of three of the most common and disabling motor symptoms: spasticity, tremor and gait impairment. Spasticity Spasticity is a common phenomenon in patients with upper motor neuron (UMN) disorders, including MS, and its pathophysiology is complex and not fully understood. Traditionally it has been defined as “a motor disorder which is a component of the UMN syndrome, characterised by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex.” 2 Some epidemiological studies indicate that spasticity is a significant problem in 60–90  % of MS patients, 3 and is a major contributor to disability in this disease. 4 The commonly used assessment scales for measuring spasticity are the Ashworth Scale 5 and Modified Ashworth Scale. 6 These scales have not been appropriately validated for use in people with MS; however, 124 they are the most used in clinics despite their limitations, since they are easy to apply and are not time-consuming. Nevertheless, changes in the Ashworth score do not necessarily correlate with changes in patient functionality. The management of spasticity is complex, requiring multiple treatment approaches. 7–10 Conditions such as urinary tract infections, pressure sores, constipation, limb pain and the use of some medications (e.g. antidepressants) can induce or worsen spasticity in people with MS. 11,12 These provocative factors need to be identified and removed (if possible), or modified before further interventions are implemented. Non-pharmacological Treatment Many physical therapeutic modalities and methods have been used in the management of spasticity, including electrical stimulation, 13 massage, cooling, hydrotherapy, 14 stretching, 15,16 and strengthening. 17,18 Among these methods, stretching and strengthening are perhaps the most common that have been used extensively in clinics. To date, there is limited evidence regarding the effectiveness of these interventions; however, they are often considered critical to the success of medical interventions for spasticity. For example, it has been shown that stretching may enhance the benefits of baclofen 19 or botulinum toxin injections used for focal spasticity. 20 A recent Cochrane review 21 focused on nine randomised controlled trials (RCTs), which investigated various types and intensities of non- pharmacological interventions for treating spasticity in adults with MS. These interventions included: physical activity programmes (such as physiotherapy, structured exercise programme, sports climbing); transcranial magnetic stimulation (intermittent theta burst stimulation, © TOUC H ME D IC A L ME D IA 2013