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MS Spasticity Causes and Treatments
Spasticity is one of the most common and challenging symptoms of multiple sclerosis (MS). MyMSTeam talked with Dr. Aaron Boster, a board-certified neurologist and president of The Boster Center for Multiple Sclerosis, about how to manage it.
00:00:00:00 - 00:00:43:19
Eric Peacock
You touched on spasticity. Just for those who aren’t aware of what it is, could you define what that means in MS?
Dr. Aaron Boster
Yes, yes. So when you — when I want to bring this can of carbonated water from an outstretched arm to my mouth, two things have to happen. My bicep muscle has to get shorter, it has to contract, and my tricep muscle has to relax, right?
00:00:43:21 - 00:01:09:02
Dr. Aaron Boster
Both have to occur. And I don’t say, “Bicep, contract. Tricep, relax.” I just say, “Ooh, beverage.” And in fact, my brain and spinal cord turn off my tricep. And so that’s this coordinated symphony. When you have damage to the brain or spinal cord, from a stroke, from MS, from traumatic brain injury, from a multitude of things, it can interrupt that.
00:01:09:08 - 00:01:29:21
Dr. Aaron Boster
And maybe when the bicep’s trying to contract, the spinal cord didn't tell the tricep to turn off. So the tricep’s also trying to contract. So now you have a tug of war between your own muscles. And it manifests clinically in three ways. A limb that’s hard to bend, like, you can’t bend your knee or you can’t bend your elbow.
00:01:29:23 - 00:01:46:18
Dr. Aaron Boster
And so sometimes it’s hard to get into a car, or like sit down in a chair, ‘cause you can’t get your legs to bend. A second thing is a cramp. And that’s like a visible contraction of the muscle, like a charley horse, and they hurt like the dickens. I’ve watched cramps drop a guy to the floor, with excruciating pain.
00:01:46:18 - 00:02:09:12
Dr. Aaron Boster
You know, the back muscles cramp up, and those are huge powerful muscles. And the third thing is a spasm, which is actually a — like, when your doctor does the reflex test. It’s like an exaggerated reflex that won’t stop. And so clinically, that’s what spasticity looks like. It’s always worse when you’re still. So at night, like, when you’re not moving around, you get stiffer.
00:02:09:14 - 00:02:32:14
Dr. Aaron Boster
And it’s always worse when it’s cold outside, which happens a lot here in sunny Ohio. And upwards of 70 percent of people impacted by MS have some form of spasticity, you know, varying degrees. Some people, just at night, their leg gets a little stiff. Some people, it’s the bane of their existence, and it almost defines their day to day life.
00:02:32:16 - 00:02:57:22
Eric Peacock
And what are the tips you give those patients who are experiencing that, and how they can deal with it, both, I guess, pharmaceutically and non-pharmaceutically?
Dr. Aaron Boster
Sure. So, first we have to identify that it’s spasticity, it’s not weakness, it’s not unsteadiness or incoordination. You know, and we do that by taking a careful history, and by examining the patient.
00:02:57:22 - 00:03:29:17
Dr. Aaron Boster
So we make sure that we know what we're talking about. And then there’s lots of things, once we identify spasticity, one of the very, very best tips, honestly, is stretching. Stretching your muscles has no benefit tomorrow, but it helps a lot right now. And I try to help my patients get into the habit of, wake up, before you exit your bedroom, stretch for five minutes. And you want to hold each position for 30 seconds because if you hold it less than 30 seconds, your muscles don’t ever learn, like, what you’re actually trying to figure out.
00:03:29:19 - 00:03:51:15
Dr. Aaron Boster
And by the way, like, 30 seconds is a really long time. Like, we’re not talking about, you know, 10 seconds. So stretching when you wake up in the morning before you leave the bedroom. Stretching when you reenter the bedroom at night, before you go to sleep. And then once in the middle of the day. Similarly, you may find that if you sit for long periods of time, it gets worse.
00:03:51:17 - 00:04:12:02
Dr. Aaron Boster
So, when you're sitting at your desk at work, and you find, you know, “If I work for an hour and then I get up, I don’t have any spasms, cramps, I’m good. If I go an hour and a half, I start to cramp up.” So I asked those people to set a timer, and every hour to every hour and 15 minutes, they get up and they do a lap.
00:04:12:04 - 00:04:30:21
Dr. Aaron Boster
And that way — and the same thing when driving in the car. I have some patients, they traveled in a car, two hours to come to our clinic. And they find if they motor the full two hours, they can barely get out of the car when they arrive. So halfway between, you know, at one hour, they get out and they walk around for a few minutes, and then that makes it OK.
00:04:30:21 - 00:04:57:16
Dr. Aaron Boster
So, that’s a third tip that I think is really important. Another one is spasticity is worse if you’re exhausted. Spasticity is worse if you’re constipated, if you have a full bladder, if you have a wound, even if you have a thumbnail, anything that’s a noxious stimulation can kick spasticity up. And so we want to pay attention. For example, if you’re really constipated, believe it or not, it can make spasticity worse.
00:04:57:18 - 00:05:19:08
Dr. Aaron Boster
Being adequately hydrated can make a really big difference with spasticity. And so making sure that you’re doing a good job — I like my patients to drink one glass of water with each of three meals, and then one glass of water between each meal. And that gets them started on a healthy amount of water that they’re drinking. Movement is key to minimize spasticity.
00:05:19:10 - 00:05:41:19
Dr. Aaron Boster
And so if you’re an exerciser, exercise, if you can walk, walk, if you can get in a pool and swim, swim. But movement can be very, very helpful with spasticity. As far as medicines go, it really depends on are you only spastic in your hand, a focal spasticity? Or is it, you know, more diffused, like the entire left side?
00:05:41:21 - 00:06:03:08
Dr. Aaron Boster
If it’s a focal spasticity, we might use things like Botox to poison the muscle just a tiny bit to get it to relax. Not too much or it wouldn’t work, but Botox can help with focal spasticity, like in a bicep, for example. If it’s more diffused, like, it’s both your legs — you can’t Botox both your legs, it’s too much surface.
00:06:03:09 - 00:06:26:06
Dr. Aaron Boster
And so then we have to use systemic treatments. And there are oral medicines like oral baclofen, Baclofen is a medicine, one of the first-line drugs that's used. In baclofen, gives you the neurotransmitter that you’re missing, the GABA. And so it can help with stiff muscles. There’s other medicines that are oral, like Zanaflex, is another one that particularly can help with spasms.
00:06:26:08 - 00:06:52:18
Dr. Aaron Boster
And so sometimes we can use oral medicines. Now oral medicines are tricky because they can create a lot of side effects.
Eric Peacock
And just a question on that. Are you deficient in the GABA because of MS?
Dr. Aaron Boster
Because of the damage to the spinal cord.
Eric Peacock
I see. OK.
Dr. Aaron Boster
So not MS in and of itself, but what MS did to the spinal cord. It damaged the area where you have GABA, and so you don't have enough, you're deficient.
00:06:52:18 - 00:07:21:18
Dr. Aaron Boster
And so baclofen is actually, chemically, is actually synthetic GABA. It's like they made the neurotransmitter and you swallow it. Now, interestingly, guess how much oral baclofen gets to the back of the spinal cord? Guess what percentage? It's crazy.
Eric Peacock
30 percent.
Dr. Aaron Boster
4 percent.
Eric Peacock
Oh my gosh.
Dr. Aaron Boster
Yeah, because when you swallow it, some of it’s dissolved by saliva and stomach acid.
00:07:21:20 - 00:07:48:16
Dr. Aaron Boster
And then once it’s in the bloodstream, about half of it is taken out by the liver. And then the stuff in the bloodstream has to cross the blood brain barrier to get into the spinal sac. But the blood-brain barrier is made of fat, it’s made of lipids. Baclofen sticks to fat and so very little crosses over. So sometimes the dose of oral baclofen you need to penetrate the central compartment would put you into a coma, you know, because of the side effects.
00:07:48:18 - 00:08:18:02
Dr. Aaron Boster
And in patients like that, we can actually implant — it’s called a baclofen pump in their body. It’s a small surgery, and it drips Baclofen targeted into the fecal sac. And so, we can give them liquid baclofen, super, super small doses. So the side effects of peripheral baclofen aren't there. And they can have a very profound effect, that’s called intrathecal baclofen therapy, or ITB.
00:08:18:04 - 00:08:41:07
Dr. Aaron Boster
And it’s something that some people with really severe spasticity, massively benefit from.
Eric Peacock
And who would be a good candidate for that? So obviously somebody with severe symptoms of spasticity.
Dr. Aaron Boster
So who’s a — now, I look for people who are a candidate for a trial, a test dose, because baclofen, you can actually do a test dose. And so if you meet four criteria then I offer you a test dose.
00:08:41:07 - 00:09:02:00
Dr. Aaron Boster
Criteria number one is you’re spastic. Again, we have to make sure that it’s actually spasticity. Criteria number two is, you don’t like it. Because some people are spastic and it doesn’t bother them, and we’re not going to discuss a pump test dose. But if they are spastic and it bothers them, then the third thing is what’s currently going on, isn’t working.
00:09:02:02 - 00:09:22:20
Dr. Aaron Boster
So right now, you’re taking two oral medicines, and Botox, and splinting, and therapy, and it’s not working. And then the fourth one is you have to be a reliable human being that I can trust, because if you have a baclofen pump and it runs dry, you could get hurt. And so I need you to be like really invested in your care.
00:09:22:20 - 00:09:43:04
Dr. Aaron Boster
So if you have those four things going on, I will offer you a baclofen test dose. And that’s when you come in in the morning and we assess how stiff you are. We actually do a lumbar puncture right at the bedside, and we squirt in liquid baclofen that takes like five minutes. And then we monitor you the whole course of the day.
00:09:43:06 - 00:10:02:20
Dr. Aaron Boster
And we see, when we bathe the spinal cord in baclofen, what happens? It’s like test driving a car. You know, you can take a car out and drive it around for 20 minutes, and you don’t know everything there is to know about the car. But you know if you like the way it handles, enough that you can then make an informed decision about if you buy it or not.
00:10:02:22 - 00:10:16:06
Dr. Aaron Boster
And one of the cool things about baclofen pumps is you can do a test dose, and kind of in the same way, figure that out.
Spasticity (muscle stiffness or rigidity) is one of the most common — and may be among the most challenging — symptoms of multiple sclerosis (MS). According to Johns Hopkins, an estimated 80 percent of people with MS have spasticity. In addition to causing pain, muscle spasms and stiffness can interfere with daily life by limiting mobility.
“Spasticity is my worst symptom so far,” shared one member of MyMSTeam. Another member experiencing muscle spasms wrote, “I can’t sit for extended periods of time, drive for any distance, or get a good night’s sleep. I’m constantly repositioning my body to find a position that doesn’t add to my discomfort.”
More than 17,000 members of MyMSTeam report that they experience spasticity. In this article, we’ll take a look at potential causes of and treatment options for this widespread symptom of MS.
In people with MS, the body’s immune system targets the protective myelin sheath around nerve fibers. When the sheath is attacked, myelin is lost and replaced with scar tissue. As nerve fibers lose the protective myelin, they lose the ability to carry messages effectively to and from the brain.
Spasticity occurs when specific parts of the brain and spinal cord are damaged. Areas of the central nervous system (CNS) that regulate muscle control are affected by an imbalance of neurotransmitters (chemical messengers), including gamma-aminobutyric acid (GABA). GABA calms the nervous system by obstructing certain brain signals. Disrupting these signals can keep muscles from relaxing normally.
Nerve damage can also cause other MS symptoms, such as sensory symptoms (like numbness or tingling), pain, and itchiness.
Many treatment options can be used to reduce symptoms of MS spasticity. Physical therapy, medication, and lifestyle changes may help ease muscle spasms and improve your quality of life. Talk to your health care provider about which options might work best for you.
Physical therapy is the first-line treatment for MS spasticity. A physical therapist can lead you through certain exercises to help stretch and strengthen your muscles. Goals of your individual exercise plan may be to improve both your mobility and range of motion. It’s important while exercising to avoid overexertion, which can result in fatigued muscles.
Aquatic therapy — performing exercises in a swimming pool — may help ease spasticity symptoms in people with MS. Stretching and range-of-motion exercises require less effort in water. A water temperature of around 85 degrees Fahrenheit is best for people with MS.
Occupational therapy helps you modify activities to ease daily life. This type of therapy aims to increase coordination and strength by exercising small muscle groups. Therapists can show you more efficient ways to perform everyday tasks, such as getting dressed or showering, using the least amount of energy.
Other types of at-home exercises may also help manage spasticity symptoms. “I found a yoga video that focuses just on stretching the legs — so far I’m liking it!” one MyMSTeam member said.
Others swear by The MS Gym, which offers free MS exercise videos. “It’s the best thing to ever come along for MS and exercise,” one member said. Another fan of these programs added, “I’ve been able to relieve spasticity in my legs with daily workouts.”
Your health care provider may recommend orthotics such as a brace or splint to keep joints stable and properly aligned during spasms. The best-fitting devices are typically those custom-made by an orthotist. Orthoses may also help prevent spasms and reduce muscle tightening.
Medications may be prescribed when spasticity symptoms interfere with sleep or daily functioning. Generally, these medications are taken orally (by mouth).
According to the National Institute for Health and Care Excellence, certain medications should be tried first for MS symptoms. If these first-line options aren’t effective or cause too many side effects, other drugs can be tried. Treatment options for MS muscle spasms include:
Many members of MyMSTeam take baclofen for spasticity. Results vary for each person. “I’ve taken baclofen for years. It works about 50 percent of the time,” said one member. Another added, “I've been on it for years and went from multiple daily spasms to just a few a month.” Some people find that the medication doesn’t help them, or they can’t continue taking it because the side effects are too hard to handle.
Baclofen and other MS spasticity medications may have significant side effects, including:
It’s important to carefully follow your doctor’s directions while taking these medications to avoid potentially dangerous side effects.
Read about safety tips for using muscle relaxants.
Another way to receive baclofen is through an intrathecal baclofen (ITB) pump, a device surgically placed under the skin of the abdomen. If you have severe spasticity and oral medications don’t help, your health care provider might recommend an ITB pump. For some people, baclofen delivered this way causes fewer side effects than when taken by mouth.
Several MyMSTeam members have reported good results with ITB pumps. “I had a baclofen pump implanted, and now I can stand up straight, have no pain, and feel like a normal person again,” shared one member.
“The pump was the best thing for me. I can’t believe how much better I am!” said another.
Botulinum toxin (Botox injection) is sometimes used as a local muscle relaxant for spasticity. Botox injections work by paralyzing spastic muscles, allowing them to relax by preventing them from contracting. Symptom relief can last several months, with injections typically repeated every three months. Botox injections are usually well tolerated, though their effectiveness may decrease over time.
“My ‘frozen solid’ muscles are beginning to ‘thaw’ with it,” said one MyMSTeam member regarding this approach. Another added, “I’ve been doing it for years, and it helps me.”
Many people living with MS report that its emotional impact influences their quality of life. Complementary alternative medicine (CAM) techniques such as guided meditation and deep breathing may help reduce spasticity symptoms. Relaxation techniques that require controlled tensing and releasing of muscles may be especially helpful.
Medical cannabis and cannabidiol (CBD), where legally available, may be used to manage MS symptoms like spasticity, according to the National Multiple Sclerosis Society. Studies suggest that noninhaled cannabinoids may provide a small improvement in MS spasticity symptoms. Other studies have found that cannabinoids can help manage spasticity, especially when related to pain or combined with other treatments. Research findings have shown inconsistent results regarding the effect of medical cannabis and CBD on other MS symptoms, however.
Many members of MyMSTeam report success with medical marijuana. “My doctor was amazed at the difference CBD oil made in my leg spasticity. He’s now recommending it to his other spasticity patients,” one member said.
Cannabis may bring fast relief. “All my muscles relax within minutes,” one member reported. “Why wait an hour or more for a muscle relaxer to work when you can immediately stop the spasticity?”
Acupuncture is another CAM technique that may provide some symptom relief. A MyMSTeam member noted that acupuncture and massage helped them: “It gives me some temporary relief.”
Being aware of your spasticity triggers can also help you manage symptoms. Common triggers that can start or increase spasticity include:
“I can function until I have a bad day with my neck, and the pain is terrible,” said one member regarding their spasticity. “I also find stress a big trigger. I try to stay chilled.”
MyMSTeam members often share tips that have helped their spasticity symptoms. Their advice includes:
Always talk to your doctor before making significant changes to your diet or trying a form of CAM, such as homeopathy, or a new supplement. The U.S. Food and Drug Administration (FDA) does not regulate supplements as rigorously as it does medications. Your health care provider can guide you on the approaches that may be safest and and most effective for managing your spasticity and other MS symptoms.
MyMSTeam is the social network for people with MS and their loved ones. Here, more than 217,000 members come together to ask questions, give advice, and share their stories with others who understand life with MS.
How does spasticity affect your daily life? Have you found an effective way to manage your spasms? Share your experience in the comments below, or start a conversation by posting on your Activities page.
Chiara Rocchi, M.D.
completed medical school and neurology residency at Polytechnic Marche University in Italy.
Learn more about her here.
Kate Harrison
writer at MyHealthTeam with nearly a decade of experience in medical publishing.
Learn more about her here.
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5 times it has affected my left knee and I've been stuck with physio. 1 of these episodes left my left foot upwards at my toes. Very painful. Lyrica didn't help as that was all I was offered
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