Managing spasticity and muscle spasms in multiple sclerosis

Treating spasticity and spasms includes a mix of self-management, physiotherapy, occupational therapy, medication and other specialist services. Both symptoms are easily aggravated, so it's essential to learn about their different trigger factors. Monitoring symptoms and making time to stretch and move as much as possible every day, are also key. Persevere as it can take time to find the best approach for you.

Managing spasticity and spasms is multifaceted and requires a team of health professionals working with you to maintain effective movement, posture and positioning. Your team may include a physiotherapist, nurse and doctor, though this can vary around the country. Together, you will agree an action plan that's achievable and shaped around your goals.

Your team will assess, monitor, support and guide you, but much of your symptom management takes place at home. This does place a certain onus on you to move and stretch as part of your daily routine, learn about trigger factors, take any medication as agreed, and report back on how you feel your symptom management plan is working. For the plan to work effectively, your involvement is important, so do share any concerns you have with your team. Your health professionals will listen closely to your feedback and use it to make adjustments to your care. 

Your specific needs will determine who else is involved in your symptom management, and this may include occupational therapists, seating and wheelchair services, orthotists (specialists in splints), bladder, bowel or skin specialists and community rehabilitation.

Physiotherapists play an important part in managing spasticity and spasms, and their involvement in your care usually begins when you're referred for an initial assessment.  

They specialise in:

• keeping your muscles, ligaments and joints as flexible as possible
• assessing which stretches and positions will help you most 
• checking whether your posture or particular movements are aggravating your symptoms
• helping prevent any further loss of movement from muscle shortening which can lead to contractures, where a limb fixes in one position permanently
• identifying muscle weakness, which often coexists with spasticity. People with MS can describe weakness like spasticity, as feeling 'heavy'. Your healthcare professional will want to find out if you have weakness, spasticity or both, as this will determine your treatment plan and medication.

To help manage your spasticity and spasms, they will tailor an exercise and stretching programme for you to continue at home. 

Stretches take time and are an ongoing commitment, so it's worth asking your physiotherapist what you can expect in terms of outcome. For some, this may mean working to maintain existing function and preventing any further loss of movement. Others may reclaim a degree of movement, and how much will depend on the severity of your symptoms. 

If moving is difficult, the physiotherapist may recommend a carer, family member or friend stretches your limbs for you. This is called passive movement, and your physiotherapist can show you both how to do this safely and effectively so your muscles are correctly aligned. If you have a care package, it may be worth asking if your carer can carry out these stretches. 

In some instances, they may introduce standing exercises which can be tailored to a range of abilities. These may be of benefit whether you can stand independently, need splints for support or spend most of the day sitting in a chair or wheelchair.

You can read more about physiotherapy here.

A critical part of any plan to manage spasticity and spasms is self-management, and this involves exercising, stretching and getting to know your symptom trigger factors as part of your daily routine:

Moving, stretching and exercising

Regular exercise helps reduce spasticity, spasms and the chance of contractures forming. This can involve a mix of stretching, strengthening and cardiovascular exercises, but if your movement is heavily restricted, even the smallest amount of exercise will benefit you. Stretching and moving your body as much as you can, will help keep your muscles, ligaments and joints supple. 

If you find your motivation slipping – and let's be honest this can happen whether or not you have MS – try to set some realistic goals with your physiotherapist that you can work towards. They can suggest ways of weaving your stretches into your day, so they feel less onerous.

You can read more about exercises for people with MS here.

Learning what may trigger these symptoms 

Spasticity and spasms are easily aggravated by things that may at first seem unrelated. Common triggers include other MS symptoms, infections, broken or red skin, poor posture, tight-fitting clothing or being too hot or cold. If you are experiencing worsening stiffness or spasms, resolving any active trigger factors may help reduce your symptoms without the need for increasing spasticity medication. Being able to identify potential triggers, is essential for managing your spasticity and spasms successfully. To help with this, we recommend you take a look at our detailed list of trigger factors, which also explains who to turn to for help. 

Below we have summarised a few key examples:

• Bladder and bowel problems: these are common in MS and are a major cause of worsening spasticity and spasms. You may have difficulties emptying your bladder completely or have a urinary tract infection? Perhaps you're experiencing difficulties with constipation or diarrhoea? Whatever the symptom, get in touch with your health professionals. These symptoms will need resolving first before any changes are made to your spasticity treatment plan. They may refer you on to a continence service. Bladder and bowel issues can be successfully managed, relieve your spasticity and spasms and boost your quality of life. 
• Poor posture and positioning: maintaining good posture while lying, sitting or standing can help reduce your spasticity and spasms, lessen your discomfort and help prevent a contracture from forming. Poor postures can distort your body's alignment, causing pain and putting pressure on your skin, which can aggravate your symptoms. There are a number of things you can do to try and break this cycle. Regularly changing your position is really important, for example from lying to sitting or sitting to standing. If you can, try to move every part of your body during the day. Your physiotherapist can advise on positioning and appropriate stretches, which can be useful before you switch positions. We also have a number of video resources on how to improve posture. An occupational therapist can introduce appropriate support aids and refer you to a specialist seating service. 
• Pain: spasticity and spasms are not always painful. However if they are, seek advice from your health care team. They may advise medication, exercise or equipment changes.
• Changes to skin: any evidence of redness, irritation, broken skin, blisters, infection or pressure ulcer (also know as pressure sore) can worsen your spasticity or spasms, so it's important to get these addressed as soon as you or your carer spot them. Speak to your health care team or GP. You may also need referral for help with posture and promoting healthy skin.

Occupational therapists assess your home and work situation and advise on strategies that can assist with daily living. This may include advice, education, equipment and adaptations with the aim of improving your quality of life such as:

• help with everyday life: they can explore ways to make your day-to-day tasks a bit easier at home, work and when you're out.
• posture support: aids such as T-rolls, E-rolls and carefully positioned pillows can help improve your alignment and comfort. Referrals to an orthotic service or a specialist seating and wheelchair service may also be recommended.
• orthotics, casts and splints: can help prevent muscle shortening, this helps to maintain movement and prevent contractures. They are usually tailor-made and used alongside medication and stretches. The therapist will advise on how long to wear the orthotic as care needs to be taken not to cause skin redness or breakdown. The medication helps to reduce stiffness and the programme of stretches will help to maintain your movement. Orthotist Emma Davidson explains how they can help with walking difficulties, but they can also help with hands and arms. 

You can find more information on occupational therapy here.

Medication is never the answer alone when managing spasticity and spasms. If it’s recommended by your health care team, it should be used to complement physical and self-management strategies by helping to improve function and reducing troublesome symptoms.  

It can be a careful balancing act, finding the right approach for you.

Although medication can reduce stiffness and make it easier for some people to move, others use their spasticity in their leg to help them transfer or walk. Some people have underlying weakness in their muscles, so removing too much spasticity leaves them unable to support themselves. 

Timing is also an important consideration. For instance, if you struggle to get up, wash and dress, 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 getting up.

First-line medication

The National Institute for Health and Clinical Excellence (NICE) guideline recommends the first line of treatment is oral baclofen.

Treatment starts with a low dose and gradually increases until you reach a level that helps you best. This approach can also help to limit side effects. It can take some weeks to reach the optimum dose. Sticking to the agreed dosage and timing of your medication will help your health professional accurately assess the effectiveness of the medication. If you have any concerns, speak to them first before making any changes.

Once you have reached the optimum dose, NICE recommends that your medication is reviewed at least annually. 

If baclofen isn't helping then gabapentin is likely to be offered next. A combination of baclofen and gabapentin may also be tried.

Note that NICE recommends that you should discuss implications of each medication with your health professional team, so you can make an informed decision about the best approach for you.    

Other medications

If your spasticity is significantly affecting your mobility, posture and ability to do things and has not responded to initial treatments, NICE recommends that you are referred to a specialist spasticity management team for further assessment and treatment. 

It is only after the previous options have been explored and ruled out that the following treatments may be considered: 

• Tizanidine or dantrolene are other possible treatments. Pregabalin, diazepam and clonazepam are sometimes used to treat spasticity and spasms
• Sativex: a cannabis-based mouth spray prescribed for moderate and severe symptoms that do not respond adequately to other medications
• Botulinum toxin (Botox): temporarily weakens muscles for about three months. Treatment is used alongside physiotherapy
• Intrathecal baclofen: if other treatment options are ineffective, a small pump can be surgically inserted in the abdomen to deliver a small dose of baclofen around the spinal cord
• Phenol: permanently stops nerve messages to the lower body. It is only used with severe spasticity that hasn't responded to other treatments.

Any review should allow enough time for your drug treatment or therapy to work. Knowing what to realistically expect from each aspect of your symptom management can help with this, so do ask your health professionals:

• what effect is the medication or therapy likely to have?
• are we aiming for maintaining current levels of movement or can I expect an improvement? 
• when can I get reviewed?

If by then, it's not making a difference, ask your health professional whether any adjustments are needed or a different approach.

To get the best out of a symptom management plan, try to follow the advice of your health professionals. Are you taking your medication on time? The agreed dose? Have your spasticity or spasms been aggravated by trigger factors? 

These are tricky symptoms to manage and may require some trial and error to find the best approach for you. 

Symptoms can also change over time so existing management plans will need reviewing and may require a new approach. Always remember that your concerns and wishes matter, so do share these with your health professionals – it takes a team to manage these symptoms successfully.