Muscle Spasticity and MS

Managing Muscle Spasticity and Spasms

Spasticity and muscle spasms can have a big impact on
quality of life and daily activities for many people with
MS. A recent survey of over 10,000 participants in the
North American Research Committee on Multiple Sclerosis (NARCOMS) registry showed
over 80 percent reported experiencing spasticity. More than 35 percent of respondents
were moderately or greatly bothered by stiffness, spasms, or pain, predominantly in the
legs. Data suggest the level of spasticity corresponded with an individual’s level of
disability, bladder dysfunction, and fatigue related to MS. Most reported receiving
treatment for spasticity (mainly oral medications, stretching, home exercise, and physical
therapy), yet fewer than half reported being satisfied with their current treatment.
Spasticity and spasms can occur in any muscle. Nerve pathways that connect the brain,
spinal cord and muscles work together to coordinate smooth movement. When
demyelination occurs along one of these nerves, signals are interrupted and the affected
muscle can remain in its shortened state, making the limb it controls feel stiff or tight and
often difficult to move (spasticity). When spasticity is severe it can be very difficult to bend
a limb at all. If a limb becomes fixed in one position it is known as a contracture.
Disrupted nerve messages can also cause over activity of muscles, leading to spasms. This is

TM a sudden involuntary tightening or contraction of a muscle which may cause a limb to kick
out or jerk towards the body. There are several different types of muscle spasm. Flexor
spasms, as the name implies, cause a limb to bend and extensor spasms cause a limb to
extend. A spasm that causes a limb to be pulled in towards the body (for example, making
it difficult to separate the thighs) is called an adductor spasm. Spasms affecting the trunk
can cause the back to arch off of a bed or away from the back of a chair.

It isn’t unusual for individuals with tight or hyperactive muscles to also
experience pain, weakness and clonus (involuntary muscle contractions).
The intensity of symptoms can vary from person to person, and in the
same person over time (even throughout the day). This can impact many
physical activities such as walking, transferring, sexual activity, washing,
dressing, and picking up objects. If muscle spasticity/spasms and their
accompanying symptoms cause an individual to fall, their safety may be compromised.
These troublesome symptoms may also have an emotional impact, for example on mood or
self-image. It’s important to note that muscle stiffness can sometimes be helpful, especially
for individuals with leg weakness. It can provide stability and strength when standing,
walking or moving from one position to another.

A number of factors play a role in the amount of stiffness
and spasms an individual may experience. For example,
lack of movement often worsens spasticity. Unpleasant
sensations, such as hunger, pain or a full bladder/bowel
can have the same effect, as can anything that constricts the
limbs, such as a cast, brace or tight-fitting clothing. Some
women find that their spasticity is worse during a
menstrual cycle. Any infection can aggravate stiffness and spasms until it has resolved,
including urinary tract infections, an infected tooth and common illnesses like a cold, flu or
stomach bug. Being overtired or stressed can also temporarily worsen symptoms, as can
being too hot or too cold. People with MS may also experience higher levels of spasticity
during an exacerbation, or when they are treated with certain disease modifying therapies or
antidepressant medications. Some find it helpful to keep a journal of when spasticity occurs,
including their activities and other environmental factors. Being aware of and managing
potential triggers for spasticity is key to successful treatment. Once they are dealt with,
muscle stiffness and spasm may ease without medication.A variety of drug-free approaches are often used to treat muscle spasticity and spasms.

Research shows that physical activity is helpful in this regard, however it’s important to note
that people with MS should consult with their healthcare team before beginning a new
exercise regimen on their own. As discussed in our November 2019 newsletter, a physical
therapist can teach specific stretches and exercises to help relax muscles, provide advice on
posture or different ways of moving and positioning the
body to keep comfortable. An occupational therapist can
provide guidance on making daily tasks easier. Research
results on the effectiveness of hot and cold therapy for
stiff muscles are mixed. A 2019 study suggests that ice
packs are effective at providing relief. On the other hand, a 2013 study concludes applying
heat makes muscles more flexible and cold treatment may have the opposite effect. Yoga,
massage and relaxation techniques like meditation and deep-breathing exercises can also be
beneficial to improve flexibility.
A variety of medications are also used to treat spasticity, often in combination with nondrug approaches when they don’t provide sufficient relief. Baclofen is commonly prescribed
to treat this condition. It can be taken orally, or via infusion directly into the spinal cord
(intrathecally). This involves the placement of a catheter into the
space around the spinal cord (the thecal sac).

The catheter
connects to a reservoir and pump that is surgically implanted in
the abdomen and programmed to continuously deliver baclofen
directly to the spinal cord. The pump is comfortable for most
people and doesn’t hamper movement. Refills are done by subcutaneous injection into the
pump’s port. A 2017 review found up to 75 percent of patients experience adverse side
effects including fatigue, dry mouth, dizziness and nausea when taking oral baclofen. When
given intrathecally, much more of the medicine reaches the spinal cord (so less is needed),
resulting in fewer side effects. Researchers conclude that, while oral baclofen is effective in
the management of spasticity, intrathecal baclofen is a viable option for those that cannot
tolerate taking it orally, or those that do not respond to the maximum recommended oral
dose.

Other drugs used to treat increased muscle tone include Zanaflex (tizanidine), Dantrium
(dantrolene), Klonopin (clonazepam) and Neurontin (gabapentin). Valium (diazepam) is also effective in this regard, however it has the potential for dependence and addiction. All
of these medications cause sleepiness, dry mouth, dizziness and fatigue, which can be
problematic. Timing when to take these medications during the day will often maximize
their effectiveness. For some, taking a dose a few minutes before getting out of bed works
best. For others, it may be better to wait until after getting up because some leg stiffness is
necessary to get out of bed safely.
Intramuscular injections of BOTOX (botulinum toxin) or phenol are
used to treat those with spasticity affecting a small area (focal
spasticity), or those who do not get relief from oral medications.

These injections are usually administered during a clinic visit.
Botulinum toxin and phenol are powerful neurotoxins that temporarily
block connections between the nerves and the muscles, resulting in
short-term relaxation of the targeted muscle. A BOTOX injection
typically takes effect in three to seven days and lasts for three to six months. It’s important
to note that it’s possible to build up antibodies to BOTOX, making it less effective over
time. Phenol typically takes effect immediately and lasts four to twelve months.

Surgery is sometimes used to help manage spasticity. As mentioned above, individuals
requiring intrathecal baclofen must have their pump implanted in the abdomen. Surgical
procedures, such as lengthening tendons or fusing joints, can also be used to correct any
permanent deformities that spasticity may cause.

As mentioned in our September 2018 newsletter, it is becoming more
common for people with MS to use cannabis to alleviate many of their
symptoms, including muscle spasms and spasticity. There have been
numerous studies conducted to evaluate its effectiveness in this regard.

The CAMS (Cannabinoids in MS) study looked at 630 people with MS
that were assigned to receive a cannabis product or placebo twice daily
for 15 weeks. Those taking cannabis reported significantly greater
improvements in spasticity, spasms, and sleep compared to those
taking placebo. The MUSEC (MS and Extract of Cannabis) trial looked at patients’
perceptions of changes in muscle stiffness. In this study, 279 people with MS took either a
cannabis product or placebo for 12 weeks. Those taking cannabis had almost twice as much
relief from muscle stiffness as those taking placebo and they also had improvements in spasms and sleep. Sativex (nabiximols), a cannabis-based oral spray, is the only drug
approved for treating MS symptoms. According to a review published by the American
Academy of Neurology (AAN), Sativex, oral cannabis extract and tetrahydrocannabinol
(THC) are at least somewhat effective at reducing MS-related spasticity and pain.
Researchers conclude there is not enough evidence to assess the effectiveness of smoked
cannabis for treating MS symptoms or the long-term safety of marijuana use. It should also
be noted that medical marijuana is only legal in some states, which affects its accessibility.

Muscle stiffness typically interferes with movement and function, but it can sometimes be
helpful. One of the biggest challenges in making treatment decisions is achieving the
optimal level of muscle tone for a given individual. Recognizing and fully addressing
aggravating triggers for spasticity is important. Once resolved, further treatment may not
be necessary. There are a variety of drug and non-drug approaches available which can be
used together to achieve the best outcome. The ideal therapy will differ from person to
person, and in the same person from time to time. It’s essential for people with MS to work
with an interdisciplinary healthcare team to manage muscle spasticity and spasms. Open
communication with one’s healthcare providers about symptoms, daily challenges and the
effectiveness of treatments will help provide clarity in how to achieve the best outcome and
quality of life.