Spasticity and spasms

Muscle spasms and spasticity can have a big impact on quality of life and daily activities for many people with MS. There are effective management strategies, including drugs and other therapies, which can help to maintain mobility and a pain-free life.

Spasticity is a symptom of multiple sclerosis that causes your muscles to feel stiff, heavy and difficult to move. A spasm is a sudden stiffening of a muscle which may cause a limb to kick out or jerk towards your body.

Spasticity can sometimes be helpful.  For instance, if your legs are weak, a degree of stiffness in your legs may help you walk or transfer from a bed to a chair.  Managing spasticity in MS involves an ongoing assessment of the effects of the symptom and any trigger factors that might be making it worse.  

Physiotherapists can help with stretching exercises and positioning. Occupational therapists can advise on posture and on seating and on ways to make day to day tasks easier. There are a number of drugs that can help manage spasticity in MS. Your MS nurse, GP or neurologist can advise you on this.

People with spasticity describe their muscles as feeling stiff, heavy and difficult to move. When spasticity is severe it can be very difficult to bend a limb at all.

A spasm is a sudden involuntary tightening or contraction of a muscle.

Any muscle can be affected but leg spasms and spasticity affecting the arms, legs or the trunk and back are most common.

Spasticity and spasms can range from mild to severe and can vary over time, even throughout the day. The symptoms can be annoying, uncomfortable and unpredictable. Some people find that they can be painful, affect walking and cause falls.

• A spasm that causes a limb to bend, such as causing the leg to move upwards towards the body, is called a flexor spasm

  

• A spasm that causes a limb to extend, such as causing the leg to straighten away from the body, is called an extensor spasm

  

• A spasm that causes a limb to be pulled in towards the body, such as making it difficult to separate the thighs, is called an adductor spasm

  

• Spasms affecting the trunk - the back or trunk can arch off a bed or away from the back of a chair

  

Spasticity and spasms are caused by an increase in muscle tone. Muscle tone is the level of tension or resistance to movement in a muscle. It is what enables you to move your limbs or hold a position. For instance, to bend your arm, you must shorten or tighten the biceps muscle at the front of the arm (increasing the tone) and at the same time lengthen or relax the triceps muscle at the back of the arm (reducing the tone).

Nerve pathways that connect your brain, spinal cord and muscles, work together to coordinate smooth movement.  If nerve signals between a muscle and the brain are interrupted by damage caused by MS, the muscle can remain in its shortened state, making the affected limb feel stiff or tight and often difficult to move. If a limb becomes fixed in one position it is known as a contracture. Disrupted nerve messages can also cause over activity of muscles and loss of coordination leading to spasms.

Depending on where in your brain or spinal cord MS affects nerves, spasticity can affect any muscle in the body.

Symptoms that often occur with MS spasms and spasticity include pain, weakness and clonus.

• Pain
  Spasticity and spasms are not always painful. If there is pain it may feel like a pulling or tugging of the muscles, particularly around joints, or a long lasting episode of cramp.  Sometimes spasticity and spasms can lead you to alter how you sit or lie and this can also lead to pain.  Movement and stretching exercise can help manage this.

• Weakness
  The damaged nerve pathways can make muscles stiff or weak. This can lead to some muscles being stiff and others weak in the same limb. Sometimes removing spasticity entirely is not helpful as it leaves just weakness and may make it harder for you to walk or move from bed to a chair. An assessment of your spasticity, perhaps by a physiotherapist, will identify if the stiffness in a limb is helping you function.

• Clonus
  Clonus is a repetitive, up and down movement, often seen as a constant tapping of the foot. You can reduce the effects of clonus by moving your leg or putting more weight through your leg by standing or perhaps leaning forward.

Research reports that between 60% and 90% of people with MS will be affected by spasticity at some point. Most people will only experience occasional symptoms. About one in five people reported that spasticity and spasms frequently affected their activities and one in eight described their symptoms as severe.

It is important to keep your muscles, ligaments and joints as flexible as possible. This can be done through stretching, active movement (where you move your own limbs) or passive movement (where your limbs are moved by a carer, physiotherapist or automated exercise machine). A physiotherapist can advise on how best to maintain flexibility, teach specific stretches that you can incorporate into your daily routine and ways of moving and positioning your body to prevent contractures.

Read more about exercises for people with MS

Maintaining good posture is also important, whether standing, sitting or lying down. Physiotherapists can advise you on posture. An occupational therapist can help you find adapted seating, aids to improve sleep positions and seating posture, and advise on safe use of wheelchairs.

Read more about posture

Trigger factors

Trigger factors can make spasticity and spasms worse. Types of trigger include:

• other MS symptoms - such as bowel or bladder problems or pain
• other health conditions - such as an infection or an ingrown toenail
• external triggers - such as tight fitting clothes or being too hot or too cold

Managing your trigger factors, maintaining good posture and incorporating stretches into your daily routine can help reduce the effects of spasticity or spasm without needing any medication. If you are taking medication, it will not be fully effective unless any trigger factors for spasticity are also being addressed.

Read more about spasticity triggers

Using drugs to treat spasticity and spasms effectively is a balance between reducing stiffness and not reducing strength in a muscle. If you remove all of the spasticity from a limb, the muscles may be too weak to work properly. For instance, if you have spasticity in your leg, the stiffness may help to keep it rigid enough to help you walk. If all of the stiffness is removed, the muscles might be too weak to hold you up.

There are a number of medications for spasticity. NICE's clinical guideline on the management of multiple sclerosis says that the first line of treatment should be with baclofen or gabapentin. If either of these isn't helping, a combination of the two drugs may help. If not, tizanidine or dantrolene are other possible treatments to try. Pregabalin, diazepam and clonazepam are also sometimes used to treat spasticity and spasms.

Treatment usually starts with a low dose and gradually increases until a level is reached that helps you best. 

It is important that you consider when you take them during the day to maximise their effect. For instance if you struggle to get up, washed and dressed, taking your medication 10-20 minutes before you get out of bed may ease the effort of your morning routine. If you need some stiffness in your legs to help you get out of bed safely, you may prefer to take your treatment after you have got up.

Sativex

Sativex is a cannabis-based mouth spray that is licensed for the treatment of MS spasticity. Sativex is not widely available on the NHS, other than in Wales where the drug regulator has approved treatment. It can be prescribed by a specialist doctor. If no improvement is seen within 4 weeks, treatment will be stopped, as only around half of people respond to Sativex.

If other approaches aren't helping your spasticity, the following treatments may be considered:

Botulinum toxin (Botox)

If the spasticity affects only part of your body botulinum toxin may be helpful. Botulinum toxin (botox) is injected into muscles and temporarily weakens them for about three months. During this period a physiotherapist can advise you on moving and stretching exercises that you can do to reduce the effects of spasticity in the longer-term. 

Intrathecal baclofen

Intrathecal baclofen therapy involves having surgery to place a small pump in your abdomen. The pump delivers baclofen through a fine tube (called a catheter) into the fluid space around your spinal cord (called the intrathecal space). The pump uses much smaller doses of baclofen than when you it take it as tablets and so causes fewer side effects.

Phenol

Treatment with phenol is usually only used if you have severe spasticity that hasn't responded to other treatments. Phenol is given via a lumbar puncture into the space around the spinal cord. Intrathecal phenol is an irreversible, destructive treatment that permanently stops nerve messages. This can greatly reduce spasticity in the legs but may also reduce skin sensation, affect sexual function and alter how your bladder and bowel work. If your doctor is considering treatment with phenol, you will already be aware of these symptoms and may have a urethral or suprapubic catheter, a skin management programme to avoid pressure ulcers or be using suppositories regularly.

Surgery

Surgery is rarely performed to reduce spasticity. Very rarely, an operation called Selective Dorsal Root Rhizotomy (SDR) is done, although this is more commonly performed in children with cerebral palsy. If you have contractures, your neurologist may recomend surgery once the spasticity has been effectively treated with oral medication or intrathecal baclofen.