There are several drug treatments licensed for the management of
spasticity and spasm. The MS NICE guidelines recommend that the first-line
treatment that we use is either baclofen or gabapentin. We would normally choose
one of these drug treatments and start it on a low dose and gradually increase. The
aim of the treatment is to get a balance with management of the stiffness and
spasms whilst preserving and maintaining as much muscle function and mobility as
possible. If these treatments aren't helpful individually, sometimes we will
combine them and some people get good effect from two different types of agents
used at the same time. If baclofen or gabapentin don't prove to be effective
or have side effects, the second-line treatments that we progress on to are
tizanidine, dantrolene or pregabalin. In some situations, where perhaps
night time spasms may be impacting on comfort and sleep, we can use benzodiazepine
such as clonazepam. These can provide effective relief of spasms
overnight and aids sleep. Sometimes drug treatments are not effective for
managing all the symptoms of spasticity and spasms. In those situations we
may choose to use other treatments such as botulinum toxin. Botulinum toxin is an
injection administered into a muscle which is stiff and it's usually used for
focal or specific areas of muscle stiffness, for example a hand, a foot or a
toe. Following the injections, a physiotherapist will help to set up a
programme of exercises and stretches in order to maximise the effect of the
treatment.
Being very vigilant to any trigger factors is really important for management of
spasticity and spasms. Keep an eye out for any potential infections, any
uncomfortable clothing or tight splints, keeping your toenails trimmed to
prevent any ingrowing toenails will all help with the management of spasticity
and spasm. Regular movement is also really beneficial as we often stiffen up
when we stay still for a period of time. If you can try and incorporate some
movement, whether it be by yourself or assisted by someone else, regularly
during the day and also some position changes in bed overnight. A good posture
is really important and being comfortable in the position that you're
either sitting or lying in. A therapist, either an occupational therapist or
physiotherapist, can help review how you're sitting or lying, perhaps in your
office chair or in a wheelchair or in your armchair at home, and help to
improve and then maintain your posture and thereby reduce the likelihood of
fatigue, pain or discomfort and the onset of spasticity and spasm.
The majority of individuals with spasticity and spasms report that exercises can be
very helpful in relieving their symptoms. It's really important to maintain as
much muscle mobility and strength as you can and to try and maintain flexibility of
muscles, joints and ligaments. Moving each joint and limb through its range of
motion each day can be very helpful and also stretching specific areas of
tightness or restricted mobility can also be useful. A physiotherapist can
help to guide you with a specific programme that should meet your needs and
you can then hopefully fit this into your daily routine, either carrying out
exercises at home or perhaps incorporating it into some fitness
regimes at the gym or during a sport that you enjoy.
Stiffness is often worse in the mornings because you've spent a prolonged period of
time fairly inactive in bed at night time. It is quite a common phenomenon
that many individuals with spasticity report. Some people with spasticity find
that some gentle exercise while still in the bed in the morning can help,
for example bending and straightening their legs at the hips and the knees,
perhaps a rotation of their trunk can help to move and get them started
moving more easily in the morning. For those patients taking medication,
sometimes we suggest that they take their medication as soon as they wake up.
It is safe to take any of the anti-spasticity medications on an empty
stomach so often people will keep a glass of water and their medications
beside their bed and on waking they'll take their first dose. If they then wait
10 to 20 minutes before getting up, it can help that initial stiffness in
the morning. The only time we need to be careful with
this is if there's a situation where you use your stiffness to help you get in
and out of the bed, or to help you stand. In those situations you may find it
more effective to just do the exercise before getting up and then take your
medication once you're out of bed.
Sometimes if your legs are really difficult to move exercise can be a
challenge. For some individuals, having some help with the limb movement can be
beneficial. Some individuals we may set up with a programme where their limbs are
supported on a device, perhaps a gym ball, or a use of a supportive wedge or t-roll
in which to exercise from. Some individuals find the buoyancy that water
provides helpful in exercising. It may be that you need to get some flotation aids
to help support and allow us much freedom of movement as possible.
If movement is very difficult for you to achieve on your own there's some
situations where we may train somebody else to help you with those exercises.
They may be able to support your limbs and guide them to move and produce a
more effective exercise regime. Some MS centers or gyms provide access to
equipment such as assisted bikes. These are devices that you can sit in your
wheelchair and place your legs on and they are motorised cycle which you can
help to participate in but the machine will also take you through the motion.
A lot of our individuals with spasticity find this a very effective way
of easing stiffness in their legs.
It's quite common for people to report an increase in stiffness and spasms
overnight. Some things that can be helpful are firstly thinking about your
bed and your mattress. It's really important to have a comfortable sleeping
position and it may be worth looking at your mattress and thinking about whether
it is a comfortable mattress and perhaps how long you've had it for and
whether a different mattress or bed may be more comfortable for you. If you're
comfortable in bed you're less likely to trigger the spasticity and spasm.
If the spasms want to stretch out your legs into extension, sometimes you might
find that resting with your legs in a degree of bend, for example with a pillow
under your knees or, if you have a profiling bed, using the profiling
mechanism may be helpful in reducing the number of spasms. If you have spasms that
pull your legs up towards your body you may find that lying on your side, keeping
one leg straight and one leg bent is helpful in reducing those spasms. If you
take medication to help stiffness and spasms at night, it may be useful to
think about the timing of your medication. Think about taking it about
30 minutes before you go to sleep so by the time you're ready to sleep it's
having its greatest effect.