Spasticity

What is spasticity?

Spasticity is one of the more common symptoms of MS. It can be described as involuntary muscle contractions that are not coordinated with other muscles or as stiff muscles which resist passive movement; it can also refer to a wide range of involuntary muscle spasms.

Spasticity may also produce feelings of pain or tightness in and around joints, and can cause low back pain. Although spasticity can occur in any limb, it is much more common in the legs.

It is a condition in which muscle tone becomes greatly increased. Muscle tone is what enables people to move limbs or hold a position therefore people with MS with this kind of spasticity can indeed stand up strongly however walking itself can be laboured.

What causes spasticity?

The regulation of muscles is a complex, finely controlled and delicate mechanism which involves the brain sending information to the muscles and receiving sensory feedback from them. In MS the system gets things wrong and this results in spasticity and spasms.

Spasticity can be very painful and, depending on the affected muscles, can result in an uncoordinated gait, stiff or deformed posture and shortening of the range of limb movement. It can be a permanent feature or brought on by a variety of factors such as fatigue, heat, humidity or infection or by sudden movements or position changes; it can even be triggered by tight clothing.

Other symptoms related to spasticity are :-

• Spasms - powerful uncontrollable muscle contractions which can be extremely painful and can be triggered in many ways e.g. coughing, sneezing or a full bladder
• Clonus - a repetitive movement, such as a constant tapping of the ball of the foot
• Contracture - when muscles become shortened and fix a limb in one position

How is spasticity treated or managed?

It is important to understand that left untreated, spasticity can lead to serious complications, including contractures i.e. frozen or immobilized joints and pressure sores.

There are many ways of treating spasticity and muscle tightness to prevent painful and disabling contractures in the hips, knees, ankles, shoulders, and elbows.

a) Treatment by physiotherapy

Because spasticity varies so much from person to person, it should be treated on an individual basis by a personal physiotherapist whether it be as a referral from a Neurologist to a hospital physiotherapy department, or, self-referral to a private one.

Treatment begins with the physiotherapist assessing the degree of spasticity followed by recommending ways to relieve the symptoms, including exercise, medication, changes in daily activities, or combinations of these methods. Daily stretching and other exercises are often effective in helping to relieve spasticity.

b) Drug treatment

If drugs are also needed, there are two major antispasticity drugs that have good safety records. Neither, however, can cure spasticity or improve muscle coordination or strength.

• Baclofen (Lioresal) : The most commonly used drug, is a muscle relaxant that works on nerves in the spinal cord. Common side effects are drowsiness and a feeling of muscle weakness. It can be administered orally or by an implanted pump - Intrathecal Baclofen : This is used for severe spasticity that cannot be managed with oral medication.
• Tizanidine (Zanaflex®). This works very quickly to calm spasms and relax tightened muscles. Although it doesn't produce muscle weakness, it often causes sedation and a dry mouth. In some people with MS, it may lower blood pressure.

Other, less commonly-used drugs are:

• Diazepam (Valium®). This isn’t a "first choice" drug for spasticity because it is sedating and has the potential to create dependence. However, its effects last longer with each dose than Baclofen, and small doses of Valium® may be prescribed at bedtime to relieve spasms that interfere with sleep.
• Dantrolene (Dantrium®). This is generally used only if other drugs have not been effective because can produce serious side effects including liver damage and blood abnormalities.
• Phenol. This is a nerve block agent
• Botulinum toxin (Botox®) injections. These have been shown to be effective in relieving spasticity in individual muscles for up to three months.
• Clonidine. This is still considered experimental as it is a drug for hypertension which appears to relieve spasticity

c) Self-help

Spasticity, like other aspects of MS, is in many ways unique to every individual. As with other MS symptoms, it tends to come and go and to be worse under specific conditions. Typical triggers as previously mentioned , include cold temperatures, high humidity, tight clothing, tight shoes, constipation, poor posture, and having a viral infection such as a cold or the flu, or a bacterial infection including skin sores or bladder infections. A sudden dramatic increase in spasticity, as a result of any of these conditions, can even suggest a "pseudo-exacerbation" of the MS.

There is an incorrect assumption that nothing can be done. Spasticity does not have to be tolerated and improvement is usually possible. Here are some possibilities to explore:

• Complementary relaxation techniques: These include progressive muscle relaxation, yoga, meditation, or deep-breathing exercises. None of these is a cure, but they can make it easier to sleep at night and face the next day's problems with a clearer head.
• Massage: Massage can help relax muscles and may be helpful in preventing pressure sores . However it should not be used if pressure sores or reddened areas of skin are present.
• Surgical measures: These are only considered for those rare cases of spasticity that defy all other treatments.
• Complementary therapies: These would include Acupuncture, Cannabis and mineral supplements such as calcium and magnesium

Personal Experiences

“Spasticity is probably my worst symptom and an absolute pain. You 'instruct' your limb e.g. your leg to go one way and instead of releasing in order to create flexible movement, it keeps on going in the one direction and becomes extra stiff. I'd compare it to trying influence your kids to doing anything.....you know, like how they go from the sublime to the ridiculous! How do I cope?....With great difficulty!”

“I tried Baclofen years ago and keppra, recently but without much success. My recent exercising, especially cycling has helped to strengthen my abdomen such that it is of assistance in terms of taking 'pressure' of the leg muscles for certain movements.”

“I take Tizanidine for spasticity which is helping a great deal. However, I am now exercising more - walking (with crutches), cycling on my exercise bike and swimming - because I am currently on an Expert Patient Programme course; this is proving to be most beneficial.”

“Spasticity in my right leg is my big problem. I take 3 x 10 mg tablets of Baclofen but they don't seem to help much. Exercise is the one thing that seems to loosen it up for a while. My physiotherapist has given me a set of exercises and I also go on the exercise bike for about 10 mins at a low setting. The exercise bike is good for posture and strengthening pelvic control which helps with the leg.”