Symptoms of multiple Sclerosis (MS) – Spasticity

Overview:

“The word spasticity refers to involuntary muscle stiffness or spasms (sudden muscle contractions)”

Spasticity is feeling stiffness, and involuntary muscle spasms or contractions. It’s one of the most common challenging symptoms of MS. Spasticity may be as mild as the feeling of tightness of muscles or may be so severe as to produce painful, uncontrollable spasms of extremities, usually of the legs. Muscle spasms or stiffness can affect between 40% and 80% of people with MS at some time. For most people, these are occasional symptoms. However, it feels different to different people, even to the same person at different times. There are occasions when a healthcare practitioner finds spasticity, but the person affected has no symptoms.

In any coordinated movement, some muscles relax while others contract. Spasticity occurs when this coordination is impaired and too many muscles contract at the same time. In MS spasticity can occur with active movement or be present at rest.

Spasticity in MS is believed to be 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.

What does it feel like?

Signs and symptoms are highly variable, and may include:

? reduced range of motion

? difficulty relaxing or releasing the muscles.

? clonus, which is a repetitive movement of a hand or foot.

? increased deep tendon reflexes.

“Stiffness can sometimes have a positive effect. It can help someone with weak leg muscles walk and stand.”

What causes spasticity and spasms?

Spasticity and spasms are caused by an increase in muscle tone. Muscle tone is the level of tension or resistance to movement in a muscle. It is what enables you to move your limbs or hold a position. For instance, to bend your arm, you must shorten or tighten the biceps muscle at the front of the arm (increasing the tone) and at the same time lengthen or relax the triceps muscle at the back of the arm (reducing the tone). Nerve pathways that connect your brain, spinal cord and muscles, work together to coordinate smooth movement. If nerve signals between a muscle and the brain are interrupted by damage caused by MS, the muscle can remain in its shortened state, making the affected limb feel stiff or tight and often difficult to move. If a limb becomes fixed in one position it is known as a contracture. Disrupted nerve messages can also cause over activity of muscles and loss of coordination leading to spasms.

Trigger factors:

? Other MS symptoms: bowel or bladder issues , pain, experiencing a relapse

? Other health condition : infection , skin irritation

? Eternal triggers : tight fitting clothes , or being in extreme weather ( too hot or too cold )

There are two types of MS-related spasms: flexor and extensor.

In flexor spasticity the muscles are so tight that the limbs are bent and difficult to straighten. I.e. involuntary bending.

In extensor spasticity the muscles are so tight that the limbs remain straight and are difficult to bend. I.e. involuntary straightening.

Treatment and management:

Because the condition is so individual, successful treatment of spasticity demands a true partnership between you and your doctor, nurse, physical therapist, and occupational therapist. Your family also plays an important role. The first step in building a good treatment partnership is learning about the range of available treatment strategies. “Treating spasticity is not a matter of the doctor writing out a prescription for pills and saying come back in three months." The primary goal of treatment is to reduce the negative effects as much as possible.

An MS spasticity scale , called MSSS-88 captures a person’s experience of spasticity and its impact on their life. It helps doctors understand how well MS medications, physical therapy, and other treatments are working. It is a patient-reported scale that includes 88 questions.

The scale divides the 88 items into eight subscales:

? Three cover spasticity-specific symptoms, such as muscle stiffness, pain, and muscle spasms.

? Three cover the individual’s physical functioning, such as daily living, walking, and body movements.

? Two cover the psychosocial impact, such as mental health and social functioning.

People can respond to each item using a scale that ranges from not feeling bothered by an issue to the issue having a significant effect on them. Someone with a total MSSS-88 score of 88Trusted Source is relatively unaffected by the included symptoms. However, if a person has a score of 352, these symptoms all substantially affect them.

The eight subsections of the scale highlight the complex nature of spasticity. These scales provide valuable insights into how people experience spasticity and allow doctors to gauge how to improve their quality of life.

A multidisciplinary team approach is ideally preferred that includes physical therapists, occupational therapists, and nurses to address the effects of MS on the body. And the pharmacist plays a crucial role in assessing safety of medications by conducting a thorough drug-drug interaction.

Physiotherapy:

Range of motion exercises – exercises designed to help you keep maximum movement in a joint may reduce muscle stiffness and prevent stiff joints from lack of use.

Stretching - stretching muscles can also help prevent long-term complications.

Strengthening - can help prevent weakness in muscles which can make daily activities and moving about more difficult.

Light pressure or stroking (touching the muscle may calm the message pathways and relax the muscle, allowing you to stretch or move a little further) .

Complementary therapies or meditation to help you relax.

Your doctor or MS nurse can refer you to a specialist physiotherapist.

Orthotic devices:

Such as braces and splints maintain the leg in a more normal position, which makes it easier to move around or get into a more comfortable position. These devices should be fitted by a professional. A common example is the ankle-foot orthosis (AFO), which places the ankle in a better alignment. Although you may find some of them over the counter, ill-fitting devices can aggravate spasticity and cause pressure sores or pain. Therapists can direct you to the best options and teach you how to use orthotics.

Occupational therapy:

Occupational therapists (OTs) are experts in modifications that make daily life with spasticity more comfortable and enhance independence. Individualized training can be very helpful in making daily activities such as dressing and showering easier and more energy efficient. Home modifications might include replacing small drawer pulls with large knobs, spraying drawer tracks with silicone to make the drawers glide, or lowering the clothes bar in your closets. OTs will recommend assistive devices and will often have samples you can try in order to determine what works best.

Muscle relaxants drug treatment:

While movement, through physiotherapy and exercise, is important in managing stiffness due to MS, they are sometimes not enough on their own.

Drug treatments can often help, especially when used together with physiotherapy. There are many different drugs used in the treatment of spasticity. All drugs have side effects, and your pharmacist will talk through the pros and cons of using these drugs.

Baclofen : A muscle relaxant that can reduce the number of spasms and levels of muscle stiffness.

Tizanidine : A muscle relaxant can reduce stiffness and spasms and may be particularly useful to treat painful night-time spasms. Because its effects last for only 3-6 hours, it can be best used around specific times when relief from symptoms is most important, for example at bedtime.

Gabapentin: An anticonvulsant drug that calms overactive messages in the central nervous system that might cause spasms. This drug is not used as commonly as baclofen or tizanidine to treat spasms and stiffness in MS, but it can be a suitable option for some people living with MS. Once you have started on it, gabapentin should not be stopped without consulting your physician.

Levetiracetam : Another medication used for seizure control in some forms of epilepsy. In MS, it can sometimes be helpful in improving spasticity and spasms.

Dantrolene sodium: This drug works directly on muscles, reducing their ability to contract.

Benzodiazepines: Diazepam and clonazepam

Diazepam is a muscle relaxant that can reduce stiffness and spasms. Because of side effects at higher doses, it may be more useful at night. Diazepam is no longer widely used to treat MS spasms and stiffness but can help some people if other treatments have not worked.

Clonazepam is similar but may be particularly effective for nighttime spasms.

Both drugs are 'benzodiazepines' - a type of drug that can be addictive with long-term use, so should not be taken for too long.

Cannabis-based drug ( Sativex):

Is an oral spray containing ‘cannabinoid’ chemicals taken from cannabis plants. It’s sometimes called nabiximols. Sativex works on the cannabinoid receptors in the brain and spinal cord. You start off taking one dose a day slowly adding more doses (but no more than 12 a day) until you get the most relief from your symptoms.

Botox : People whose symptoms do not respond to the above muscle relaxers may receive onabotulinumtoxinA (Botox), which temporarily blocks nerves and muscles following an injection into the area.

Baclofen pump (intrathecal baclofen)

Baclofen is supplied continuously to the fluid around the spinal cord. A pump that is surgically implanted near the waistline controls the dose. This system is known as 'intrathecal' injection. For those with more severe spasms or stiffness, who do not gain adequate benefit from tablet medications, this can be helpful. By delivering the drug directly to the area in which it works, it can be more effective. Because of this, doses can be kept lower, keeping side effects to a minimum.

Liquid phenol (intrathecal phenol):

Phenol is injected directly into the fluid around the spinal cord ('intrathecally'). It can be helpful for some people to treat very severe spasms that do not respond to physiotherapy and other drug treatments. Phenol destroys the nerves that control sensation and movement, so it is only used where a person already has limited control of these parts of their body.

Surgery

A doctor may recommend permanently cutting nerves or tendons to relieve symptoms in severe cases.

Rhizotomy is an example of an MS surgery that a person may undergo to relieve facial pain. In this procedure, the surgeon cuts away a section of the nerve to prevent nerve pain in the head and face.

Conclusion:

Spasticity is a common MS symptom. Individuals may experience pain, muscle contractions, stiffness, and uncontrollable movements that make everyday tasks challenging. It can have negative effects on an individual’s psychological health and social roles. Relationships, employment, and planning may be affected.

The reduced ability to work and the burden on a care partner are significant contributors to financial costs related to spasticity. While additional studies are needed to better understand the full impact of spasticity on individuals with MS, it’s important of early and continued treatment of spasticity, to maximize mobility and prevent the loss of productivity.

People living with MS have a range of options to help them manage spasticity. For example, doctors may recommend a combination of gentle muscle stretching exercises and medications.

To be continued .....

References:

https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Spasticity#:~:text=It%20is%20one%20of%20the,can%20cause%20low%20back%20pain .

https://mymsaa.org/ms-information/symptoms/spasticity/

https://www.mssociety.org.uk/about-ms/signs-and-symptoms/spasms-and-stiffness/treating-spasms-and-stiffness

https://www.medicalnewstoday.com/articles/multiple-sclerosis-spasticity-causes-and-management#summary

https://mstrust.org.uk/a-z/spasticity-and-spasms

https://www.ncbi.nlm.nih.gov/books/NBK62199/

https://mssociety.ca/library/document/n1MhuAUYpcI02EsKXeadBLzPTGOS7QWr/original.pdf