Ask the expert: spasticity and spasms

Have you ever experienced muscle stiffness or a heavy feeling in your muscles which makes them difficult to move? Or perhaps one of your muscles has suddenly stiffened causing your arm or leg to kick out or jerk towards your body? These symptoms are known as spasticity and spasms – they're a common symptom of MS and can have a big impact on your daily life.

To find out how spasticity and spasms can be successfully treated and managed, we put your questions to physiotherapist, Katrina Buchanan.

Katrina says: The majority of individuals with spasticity and spasms report that exercises can be very helpful in relieving their symptoms. It's really important to maintain as much muscle mobility and strength as you can and to try and maintain flexibility of muscles, joints and ligaments. Moving each joint and limb through its range of motion each day can be very helpful and also stretching specific areas of tightness or restricted mobility can also be useful.

A physiotherapist can help to guide you with a specific programme that meets your needs and you can then hopefully fit this into your daily routine, either carrying out exercise at home or perhaps incorporating it into some fitness regimes at the gym or during a sport that you enjoy.

Katrina says: Stiffness is often worse in the mornings because you've spent a prolonged period of time fairly inactive in bed at night. It is quite a common phenomenon that many people with MS spasticity report. Some people with spasticity find that some gentle exercise whilst still in bed in the morning can help, for example bending and straightening your legs at the hips and knees, and rotating your trunk. This can help you to get moving more easily in the morning.

For people taking medication, sometimes we suggest that you take your medication as soon as you wake up. It is safe to take any of the anti-spasticity medications on an empty stomach, so often people will keep a glass of water and their medication beside their bed and on waking they'll take their first dose. If you then wait 10–20 minutes before getting up, it can help that initial stiffness in the morning.

The only time we need to be careful with this is if there's a situation where you use your stiffness to help you get in and out of the bed, or to help you stand. In those situations you may find it more effective to just do the exercise before getting up and then take your medication once you're out of bed.

Katrina says: Trigger factors are sometimes known as aggravating factors for spasticity and spasm. These include things like pain, changes in temperature, fatigue, uncomfortable clothing or ill-fitting splints, and bladder and bowel problems. The reason these symptoms trigger an increase in stiffness and spasms is that they provide a sensory stimulus that is fed into the central nervous system. This ongoing, frequent sensory stimuli in turn leads to an output of increased muscle contraction and spasm. If we can help to reduce the trigger factors, this will help to relieve some of the symptoms of spasticity and spasm.

Katrina says: Being very vigilant to any potential trigger factors is really important. Keep an eye out for any potential infections, keep your bladder and bowel well managed if you can (with use of medication to ease constipation if necessary) and make sure any infections are treated promptly. Watch out for any areas of sore skin, pressure ulcers and keep your nails well-trimmed to avoid any ingrowing toenails. This will all help with the management of spasticity and spasms.

Regular movement is also really beneficial as we often stiffen up when we stay still for a period of time. If you can, try and incorporate some movement, whether it be by yourself or assisted by someone else, regularly during the day and by changing your position at night when you're in bed.

A good posture is really important and being comfortable in the position that you are either sitting or lying in. An occupational therapist or physiotherapist can help review how you're sitting or lying – perhaps in your office chair, a wheelchair or in your armchair at home – and help to improve and then maintain your posture and thereby reduce the likelihood of fatigue, pain or discomfort, and the onset of spasticity and spasm.

Katrina says: It's quite common for people to report an increase in stiffness and spasms overnight. There are several things you can try if spasticity and spasms are affecting your sleep.

• It's really important to have a comfortable sleeping position and it may be worth looking at your mattress and thinking about whether it's comfortable, how long you've had it for and whether a different mattress or bed may be better for you. If you're comfortable in bed, you're less likely to trigger the spasticity and spasm.
• If the spasms want to stretch out your legs in extension, sometimes resting with your legs in a degree of bend – for example, with a pillow or t-cushion under your knees or, if you have a profiling bed, using the profiling mechanism – may be helpful in reducing the number of spasms.
• If you have spasms that pull your legs up towards your body, you may find that lying on your side, keeping one leg straight and one leg bent, is helpful in reducing those spasms.
• If you take medication to help stiffness and spasms at night, it may be helpful to think about the timing of your medication. Think about taking it about 30 minutes before you go to sleep so by the time you're ready to sleep, it's having its greatest effect.

Katrina says: There are several drug treatments licensed for the management of spasticity and spasm. The MS NICE guidelines recommend that the first-line treatment that we use is either baclofen or gabapentin. We would normally choose one of these drug treatments and start it on a low dose and gradually increase. The aim of the treatment is to get a balance with management of the stiffness and spasms whilst preserving and maintaining as much muscle function and mobility as possible.

If these treatments aren't helpful individually, sometimes we'll combine them and some people get good effect from two different types of medication used at the same time. If baclofen or gabapentin don't prove to be effective, or have side effects, the second-line treatments that we progress to are tizanidine, dantrolene or pregablin.

In some situations, where perhaps night time spasms may be impacting on comfort and sleep, we can use benzodiazepines such as clonazepam. These can provide effective relief of spasms overnight and aid sleep.

Sometimes the treatments mentioned above are not effective for managing all the symptoms of spasticity and spasms. In those situations we may choose to use other treatments such as botulinum toxin, better known as Botox. This is an injection which is administered into a muscle which is stiff and is usually used for focal or specific areas of muscle stiffness, for example a hand, a foot or a toe. Following the injections, a physiotherapist will help to set up a programme of exercises and stretches in order to maximise the effect of the treatment.

There may be some individuals who find, despite the use of several medications, that spasticity and spasms continue to be very problematic for them. In those situations we may consider more invasive treatments such as intrathecal baclofen where we implant a small pump into the abdomen of the patient which delivers a drug into the fluid around the spinal cord and delivers baclofen directly to the place where it's needed. This can be a very effective treatment for spasticity but does require an operation.

The last treatment that we sometimes use for individuals with severe spasticity can be injections of intrathecal phenol which are given into the space and fluid around the spinal cord. They cause damage to the nerves and stop the transmission of nerve signals from the spinal cord out to the legs and can produce an effective relief of severe spasticity and spasm. They do however affect bladder and bowel function, sexual function, and can affect sensation, so we would expect to undertake these more invasive procedures with careful consideration and joint teamwork with a spasticity management service and the person with MS.

Katrina Buchanan is a consultant physiotherapist at the National Hospital for Neurology and Neurosurgery, London, where she works within the Spasticity Management Service.

This interview took place in 2018. This article has been reviewed in 2024.

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