Spasticity and spasms

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Spasticity and spasms

Date of issue: July 2011
This factsheet will be reviewed within three years

Contents

1. What are spasticity and spasms? 1
2. Managing spasticity and spasms 4
3. Getting the most from medication 6
4. Measuring the impact of treatment 10
5. References 11



Spasticity and spasms are symptoms often associated with multiple sclerosis.
However, to ensure people with MS and health professionals communicate
effectively, it is vital to appreciate what the terms spasticity and spasms
describe as misunderstandings can occur. For instance, someone might
describe their symptom as a 'spasm', using the term to mean a sudden wave
of pain, where a health professional would understand the word to mean a
sharp contraction of a muscle. Unless the meaning is properly explored and
any confusion resolved between the popular use of a word and its medical
definition, it could lead to a doctor prescribing medication that will have little or
no effect on the individual's symptom.
1. What are spasticity and spasms?
Spasticity can be described as involuntary muscle stiffness and spasms as
involuntary muscle contractions. Any muscle can be affected but spasticity
and spasms tend to predominantly affect a person's limbs or trunk.
People with spasticity describe their muscles as feeling stiff, heavy and
difficult to move. When very 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.
2
Different types of spasm
1

Spasms
Flexor spasms
The limb bends upwards towards the
person's body

Extensor spasms
The limb extends away from the
person's body

Adductor spasms
The limb pulls inwards towards the
person's body. Commonly a person
experiences this as difficultly
separating their thighs

Spasms affecting the trunk
The back or trunk can arch off a bed
or away from the back of a chair


Why these symptoms occur
Nerve pathways connecting the brain, spinal cord and muscles, work together
to coordinate movements of the body. These pathways can be disrupted in
multiple sclerosis and can lead to loss of coordination, over-activity and / or
weakness of muscles.
Spasticity and spasms can range from mild to severe and can vary over time,
even throughout one day. People can describe the symptoms as annoying,
uncomfortable and unpredictable, although they can also be helpful. Some
people use the stiffness of their spasticity or extensor spasms to assist them
when walking or in transferring from bed to chair.

3
Other associated symptoms
Other features that may be associated with spasticity and spasms can include
pain, weakness and clonus.
Pain
Spasticity and spasms are not always painful. If pain is present it can be
described as a 'tugging' of the muscles and can be as a direct result of the
sudden spasm movement or the constant feeling of stiffness. Sometimes
spasticity and spasms can lead to altered sitting and lying positions which
can also lead to pain and discomfort.
Weakness
Although a limb with spasticity is stiff and can resist movement, some of
the muscles may also be weak. It can seem paradoxical to have some
muscles that are stiff and others that are weak, but this results from
different nerve pathways being disrupted. The co-existence of spasticity
and weakness can be challenging to manage as drugs can minimise
spasticity but not weakness. Sometimes when a person's stiffness is
reduced they feel their existing weakness is more prominent.
The feeling of weakness is often described by people with the term
'heavy'. Confusingly this word can also be used to describe stiff limbs.
To assess whether the heaviness is from weakness or spasticity, it may be
necessary for the health professional to bend and straighten the limb. This
is described as 'moving the limb through its full range of motion'. A limb will
resist being moved if spasticity is present. If weakness is present, although
it may feel cumbersome and weighty, the limb will move more easily.
Clonus
This is a repetitive, up and down movement, often of the feet. It is often
observed as a constant tapping on wheelchair footplates. Individuals often
find their own ways to minimise this symptom such as lifting the limb, or
leaning forward in the chair to pass weight through the leg.
Fatigue and loss of dexterity can also be associated with spasticity.

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What is tone?
Spasticity is sometimes described as increased muscle tone. Muscle tone is
the resistance felt when an arm or leg is moved or stretched. Normal tone
occurs when an individual is relaxed and the health professional can bend
and straighten the limb without difficulty. An increase in tone can be due to
spasticity, spasms and or changes in muscles, tendons and ligaments as a
result of disuse, or altered lying and sitting postures.
2. Managing spasticity and spasms
Managing spasticity and spasms is a balance between minimising the
negative aspects and maintaining their usefulness, such as providing support
to weak muscles. Key to any long-term management plan is the need for
movement or stretching and the ongoing management of trigger factors.
Movement and stretching
It is important to keep muscles, ligaments and joints as flexible as possible.
This can be done through stretching, active movement (where the individual
moves their own limbs) or passive movement (where limbs are moved by a
physiotherapist or automated exercise machine). A physiotherapist can advise
on how to maintain flexibility, teach specific stretches, and ways of moving
and positioning the body to prevent contractures.
Similarly it is important to maintain good sitting and lying postures. This can
be assisted by adapting equipment such as wheelchairs and using aids to
improve sleep positions. Experts who can advise include specialist seating
services, physiotherapists and occupational therapists.
Optimising sitting postures
1
Poor positioning in sitting Good positioning in sitting



Hips and bottom at the back of the
seat, knees and feet at right angles

See also Are You Sitting Comfortably..?, the MS Trust's book on posture when sitting.
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What can be done and who can help
Whether symptoms are mild or severe, medical, physiotherapy, nursing and
occupational therapy treatment, advice and education can help increase
understanding of spasticity. Increasing knowledge about spasticity and what
triggers it can help people manage it more effectively and prevent symptoms.
Certain factors are known to exacerbate spasticity and spasms.
Trigger factors
1
Who can give management advice
Urinary infection or
retention

Bowel impaction,
constipation, infection

Red or broken
skin/pressure areas,
ingrown toenails

Sometimes spasticity and spasms become
harder to manage; a review of bladder,
bowel and skin care management
techniques may improve the situation.

A GP, nurse specialist, continence advisor
and / or district nurse can give advice and
assistance to effectively manage bladder,
bowel and skin.
Pain

Infections
Pain and infection will aggravate spasticity.
Locating and treating the source of the pain
or infection eg skin infection or an ingrown
toenail, may reduce the spasticity. Advice
can be sought from a GP or district nurse.
Tight fitting clothes or
splints
Simply loosening tight garments may help
to relieve spasticity. If splints are causing
discomfort or skin irritation then they will
need reviewing by an orthotic or therapy
service.

In summary, the ongoing need to incorporate movement, stretching and good
sitting and lying postures together with managing trigger factors cannot be
over emphasised. However, sometimes it is necessary to complement these
strategies with the use of drugs.
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3. Getting the most from medication
The effective use of drugs can be an invaluable part of how a person
manages their spasticity. When commencing any drug it is best to start with a
low dose and gradually increase it, until a level is reached that helps the
symptom but has minimal side effects. The oral drugs available (listed below)
can be used in combination, but usually a doctor will maximise the effect of
one drug before prescribing it with others. The doses indicated are only a
guide. A doctor will recommend the dose of specific drugs and, where
necessary, suggest how to increase the dosage.
It is important to consider the best time to take these drugs during the day.
For instance, if getting out of bed is difficult, it could be beneficial for someone
to have their drugs next to the bed, take them when they wake up and wait 10
- 20 minutes before getting up.
Available oral drugs
The NICE Guideline
2
states that the first line of treatment should be baclofen
or gabapentin. The other drugs in the list should only be given if this treatment
is unsuccessful or side effects are unmanageable.
Baclofen
Site of action - Directly on nerve cells, mainly in the spinal cord,
Initial and maximum doses - Initial dose 5-10mg once or twice a day.
Maximum dose 120mg. Baclofen works for between four and six hours so
needs to be taken regularly through the day.
Side effects - Should not be stopped abruptly as this can induce seizures.
Side effects can include weakness, drowsiness and dizziness

Gabapentin
Site of action - Central nervous system
Initial and maximum doses - 100-300mg daily up to a maximum of 2400mg
Side effects - Drowsiness, dizziness



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Tizanidine
Site of action - Central nervous system
Initial and maximum doses - 2mg daily up to a maximum of 36mg
Side effects - A doctor will initially recommend regular blood tests to ensure
tizanidine does not have any adverse effects on liver function. It can also
cause drowsiness and a dry mouth


Diazepam
Site of action - Central nervous system
Initial and maximum doses - 2mg daily up to a maximum of 40-60mg
Side effects - As a prominent side effect is drowsiness, this drug is best
taken at bedtime. Side effects include reduced attention and memory
impairment. Should not be abruptly stopped as this can cause withdrawal
effects


Clonazepam
Site of action - Central nervous system
Initial and maximum doses - 0.25-0.5mg daily up to a maximum of 3mg
Side effects - As a prominent side effect is drowsiness this drug is best taken
at bedtime. Side effects include reduced attention and memory impairment.
Should not be abruptly stopped as this can cause withdrawal effects


Dantrolene
Site of action - The only anti-spasticity drug that works directly on muscles
Initial and maximum doses - 25mg daily up to a maximum of 400mg
Side effects - Side effects are unfortunately quite common and include
nausea, vomiting, diarrhoea and weakness. A doctor will take regular blood
tests to ensure that the function of the liver is not affected


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What if the oral drugs don't help?
If the oral anti-spasticity medications prove ineffective or their side effects
unbearable, Sativex may be prescribed as an add-on treatment.
Sativex
Sativex is a cannabis-based mouth spray. It is licensed as an add-on
treatment to MS related spasticity when people have shown inadequate
response to other symptomatic treatments or found their side effects
intolerable.
Sativex can only be prescribed by a specialist doctor with experience of
treating MS spasticity, for example: consultant neurologists, consultant
rehabilitation specialists and consultant pain specialists. A specialist doctor
will conduct a full assessment of the severity of spasticity related symptoms
and an evaluation of the response to standard spasticity treatments for
individuals who might benefit from the use of Sativex.
For further information see the MS Trust's Sativex factsheet.
Other treatment options
If management strategies, therapy input and oral drugs are not providing
adequate relief, then the following treatments may be considered:
Intramuscular botulinum toxin
When botulinum toxin is injected into muscles it temporarily weakens
them. It can take 14 days for the full effect of the toxin to occur and it lasts
approximately three months. When combined with an intensive period of
moving and stretching this can lead to a reduction in spasticity over longer
periods. Advice on a specific stretching program is best provided by a
physiotherapist or occupational therapist around the time of the injections.
Intrathecal baclofen therapy
Intrathecal baclofen therapy is an alternative way of delivering baclofen
directly to the appropriate nerve cells in the spinal cord by administering it
into the intrathecal space (the space around the spinal cord within the
spine). This can be helpful for those people who find they cannot tolerate
oral baclofen. In the short-term intrathecal baclofen can be given via a
lumbar puncture. For long-term treatment a pump is required to deliver
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baclofen 24 hours a day. The system is completely implanted inside the
person with the pump surgically placed in the abdomen. The pump has a
reservoir that stores the baclofen and a catheter that links the reservoir to
the intrathecal space.
Different types of pump are available with the baclofen pumped into the
spine either electronically or via a gas-compression system. The pumps
enable much smaller amounts of baclofen to be used, reducing any side
effects that a person may have experienced when taking baclofen orally.
Embarking on intrathecal baclofen therapy is not a simple decision to
make. Not only does it involve surgery but also regular reservoir refills and,
if using the electronic model, further surgery after five to seven years when
the battery depletes. Before implantation, a trial of the drug can be given
via a lumbar puncture. This gives the person, their family and the treating
team the opportunity to experience and assess the potential outcome of
having intrathecal baclofen before committing to the surgical implant.
Intrathecal phenol
This treatment tends to be reserved for severe spasticity that is not
responding to other forms of treatment. Intrathecal phenol is given via a
lumbar puncture and requires a specialist doctor to inject it. Intrathecal
phenol is a destructive treatment that stops nerve conduction. This can
significantly reduce lower limb spasticity but negative effects can occur
such as a reduction of leg sensation, reduced sexual function, and altered
bladder and bowel function. People suitable for intrathecal phenol will
already be experiencing a change in these areas and will have effective
management strategies in place, for instance a suprapubic catheter or
regularly use of suppositories.
Surgery
Occasionally a neurologist may recommend orthopaedic or neurosurgical
procedures, although these are becoming more rare.
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4. Measuring the impact of treatment
To help understand if a particular drug or stretching regime is helping a
person's spasticity and spasms, health professionals may ask to measure a
person's symptoms. Measures are tools that use numbers or words to classify
or quantify symptoms in order to compare the degree of spasticity, spasms
and pain over time or before and after treatments.
Spasticity measures
There is no one measurement tool or scale that adequately measures
spasticity. In practice, a series of measures is often required to reflect different
aspects of spasticity.
These approaches will look at different aspects of the symptoms:
Moving limbs to physically measure the distance that they can be moved
Asking the individual to report on how they are affected by their symptom -
eg the Penn Spasm Frequency Scale involves the individual reporting the
type and frequency of spasms
Assessment of symptoms by a health professional - eg the Ashworth
Scale involves the measurer moving a limb through its available range and
assessing the level of stiffness
Evaluating and measuring spasticity in partnership
For some people, being measured can make them feel as if they are enduring
a test or being judged. The process encourages them to focus on their level of
disability, which they may not normally do; this may be emotional, challenging
and distressing. For others, the measuring process helps them to be more
specific about changes they feel in their bodies or the impact on their lifestyle.
Health professionals are advised to be alert to how a person may be feeling
and provide support through education, engagement and involvement to
enhance the measuring process
3
. Education involves explaining why
measurement is required, how it will help the assessment and the role of the
person with MS. Being involved in the process allows the person to share how
they are experiencing the changes in their spasticity and spasms and how this
may affect their function at home. It's important to remember being measured
is not a test and there is no right or wrong. It is just a baseline for comparison.
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In summary, effective spasticity management requires ongoing management
of posture through movement and stretches, the management of trigger
factors and the careful evaluation and use of drug treatments.
5. References
1. Stevenson VL, Jarrett L. Spasticity management: a practical multidisciplinary guide.
Oxford: Informa Health Care; 2006.
2. The National Institute for Clinical Excellence (NICE). Management of multiple sclerosis in
primary and secondary care. London: NICE; 2003.
3. Jarrett L. The challenge of managing spasticity: the role of the nurse in the process of
assessment and measurement? Nursing Times 2006;102(15):26-28.


Please contact the MS Trust Information Team if you would like any further information about
reference sources used in the production of this publication.


Acknowledgements
This factsheet is based on articles written for the MS Trust's Open Door newsletter by Louise
Jarrett, then spasticity specialist nurse at the National Hospital for Neurology & Neurosurgery,
London