Spasticity
Reviewed by Randall T. Schapiro, MD
President, The Schapiro MS Advisory Group
Clinical Professor of Neurology, University of Minnesota (retired)
Spasticity is a common symptom in MS. It is a tightness or stiffness of the muscles – occurring typically in the legs (calf or thigh), groin, and buttocks. Although less common, some individuals may experience spasticity in their back. These are all muscles that help people to stand and balance in an upright position.
Spasticity in MS is a result of demyelination along the nerves of the brain and spinal cord that control movement. Sometimes the stiffness caused by spasticity is slight and can actually be helpful by giving individuals more support to stand or turn. Mild spasticity is not painful. However, when spasticity is more severe, it can become painful. More energy is needed to perform daily activities when spasticity is more pronounced, causing discomfort and limiting movement.
Through different treatment strategies, spasticity can be managed. And when one’s spasticity is reduced, this in turn allows the individual to be more comfortable, stronger, and to move more freely. Fatigue is also reduced, as movements do not require as much effort. Coordination improves as well, because muscles are working together more efficiently.
Several strategies may be used to reduce the effects of spasticity. Initially, any other treatable issues that may contribute to this symptom should be addressed. For instance, if an individual is experiencing pain separate from spasticity – perhaps from an infection or a skin sore – these can worsen muscle tightness. Treating these types of underlying conditions can help to reduce spasticity.
The next step for many individuals in treating spasticity is to consult a physical therapist to help create an exercise plan, one which uses different stretching exercises that can be done at home. In the 5th edition of Managing the Symptoms of Multiple Sclerosis, examples of helpful exercises are described, as follows:
“A thorough stretching program includes a series of exercises that are performed in certain sitting or lying positions that allow gravity to aid in stretching specific muscles. While in the sitting position, a towel or long belt may be used to pull on the forefoot and ankle to stretch the calf, or to stretch the thigh muscles when one is lying on the stomach. Certain muscles may be relaxed more effectively while one is lying on the stomach or side, or while lying on all fours over an exercise ball, rocking rhythmically forward and backward.
“The simplest and often the most effective way to reduce spasticity is passive stretching, in which each affected joint is slowly moved into a position that stretches the spastic muscles. After each muscle reaches its stretched position, it is held there for approximately a minute to allow it to slowly relax and release the undesired tension. This stretching program begins at the ankle to stretch the calf muscle, then proceeds upward to the muscles in the back of the thigh, the buttocks, the groin, and, after turning from the back to the stomach, the muscles on the front of the thigh.
“Range-of-motion exercises differ from stretching exercises in that the movement about the joint is not held for any specific length of time. Although range of motion is important, holding the stretch is significant, and patience is essential when doing the stretches.”
According to the book, the key to managing spasticity is to continually increase the number as well as the type of movements used in these exercises. However, care must be taken to use the least amount of effort possible while performing these exercises, so as to not overuse any muscle groups or cause fatigue.
Another strategy is to use complementary and alternative types of treatment, such as relaxation techniques, deep breathing, and guided imagery. The relaxation techniques involve the progressive tensing and then releasing of different muscles, along with deep breathing and guided imagery. Some individuals may also benefit from acupuncture, although the reason for its benefits has not been identified. In addition, some patients may benefit by using cooling devices or ice packs after exercise to reduce spasticity.
One very helpful method of reducing spasticity is aquatic therapy or aquatic exercise (both refer to forms of exercise in a swimming pool). The natural buoyancy from activity in the water enables participants to move with less effort. Both stretching exercises and range-of-motion exercise may be performed in a pool. MSAA is developing a new program that will emphasize the benefits of swimming/aquatic exercise for individuals with MS, so please watch for future announcements on this exciting program initiative.
Please note that the temperature of the water in the pool is very important for individuals with MS. If too cold, it can cause spasticity to worsen. If too warm, individuals may become fatigued. Experts have determined that 85 degrees is about the ideal temperature for people with MS.
Beyond the treatment of underlying conditions, and an exercise plan that includes stretching, range-of-motion, and possibly aquatic exercise, certain devices may be of great assistance. These can be particularly helpful in avoiding contractures (causing reduced movement in a joint) by allowing muscles to relax while maintaining a proper position.
Examples include toe and finger spreaders as well as braces for the foot, hand, or wrist. These devices are referred to as orthoses and may be custom-made by an orthotist for an optimal fit. Many people are familiar with an ankle-foot orthosis (AFO), which holds and angles the foot and ankle in the best position for maximum comfort and mobility. It can also relieve stress on the knee.
Once exercise and devices have been employed, medication may be needed to further reduce spasticity. Baclofen is the most commonly prescribed medication to treat spasticity in MS and is usually very effective. It may be taken orally, or for individuals with more severe spasticity, given via an implanted pump that provides the medicine directly into the spinal fluid. Dosage often varies with each person and needs to be carefully monitored – since too much can cause fatigue and weakness, and too little is not effective. One benefit of the pump is that by going directly into the spinal fluid, a much smaller dose is needed to accomplish the desired effect.
Other medications are also available and may be more appropriate for some. These decisions can only be made through consultation with one’s healthcare provider. Different therapies may also be used in severe cases that do not improve with the traditional treatments. These include procedures that temporarily block the nerve and muscle (Botox® or Myobloc™ injection), among other, more permanent treatments. Examples include chemically inactivating a muscle and surgically cutting specific nerves or tendons.
The following medications may be used to treat spasticity (as listed on MSAA’s website at mymsaa.org under symptoms). Please see MSAA’s website for more information about these drugs, such as prescribing information and side effects.
- Baclofen (formerly available as Lioresal®)
- Zanaflex® tablets and Zanaflex Capsules® (tizanidine hydrochloride)
- Valium® (diazepam)
- Klonopin® (clonazepam)
- Dantrium® (dantrolene sodium)
- Neurontin® (gabapentin)
- Tegretol® (carbamazepine)
- Keppra® (levetiracetam)
- Requip® (ropinirole)
Reference
Schapiro, R. T., Managing the Symptoms of Multiple Sclerosis, 5th edition, (Demos Medical Publishing, 2007)