OT Muscle spasm/leg stiffness

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Muscle stiffness associated with MS is " spasticity " - an increase in

muscle tone that can interfere with normal movement of the affected

limb even though the strength of that limb might be normal. This

increased muscle tone is caused by a dysregulation of nerve impulses

in the spinal cord, resulting in too much stimulation in some muscles

and too little in others. Spasticity tends to occur most frequently

in postural muscles (those that enable us to stand upright),

including muscles in the calf, thigh, groin, buttock, and

occasionally the back. Spasticity can also occur in the arms. Very

mild spasticity can sometimes be managed with appropriate stretching

and range of motion exercises.

If exercises alone are too uncomfortable or do not provide adequate

relief and mobility, antispasticity medications may be used. A

variety of medications are available for this purpose, including

baclofen (Lioresal®), tizanidine (Zanaflex®), clonazepam (Klonopin®),

diazepam (Valium®), and dantrolene (Dantrium®). Your physician will

select the particular medication best suited for your needs; baclofen

is the drug most commonly used. The correct dosage of baclofen will

differ from one individual to another. The goal of treatment is to

find the dosage level that provides adequate muscle relaxation

without producing excessive fatigue or weakness. Tizanidine has been

shown to relieve spasticity without causing muscle weakness but is

often sedating.

Occasionally, people with MS-related spasticity develop flexor or

extensor spasms. These spasms, which typically last two or three

seconds, are disinhibited (hyperactive) spinal reflexes that can

occur in response to the slightest of noxious stimuli (e.g., the

rubbing of bed sheets against the foot during sleep). Flexor spasms

cause both legs to pull upward into a clenched position, while

extensor spasms cause the legs to straighten into the stiff, extended

position. These uncontrolled spasms can be sufficiently intense and

sudden to propel the person out of his or her chair. Baclofen

(Lioresal®), gabapentin (Neurontin®), diazepam (Valium®), clonazepam

(Klonopin®), and tizanidine (Zanaflex®) are the medications of choice

for the management of this problem.

In the case of severe spasticity that cannot be managed comfortably

or effectively with oral baclofen (tablets), a pump can be surgically

implanted in the abdomen to automatically administer low doses of

liquid baclofen directly into the spinal cord. The pump's usefulness

stems from its ability to reduce spasticity with a much lower dose of

medication, thus eliminating the side effects (e.g., severe

drowsiness, dizziness, weakness, or nausea) that can occur with

higher doses of baclofen.

In some instances of spasticity, Botox (made from botulinum toxin)

may be used to block a nerve's function. The Botox is injected into

the affected muscle at the point where the nerve enters the muscle,

and prevents the nerve from exciting the muscle to contract. Botox,

which can be administered by the neurologist, may require repetitive

injections to achieve sustained blockage of the nerve. It is best

used for focal spasticity in small muscles like those of the upper

limbs.

Severe spasticity that does not respond to medications, or for which

Botox is not suitable, may also be treated with a procedure called a

nerve block or motor point block. An injection of phenol into the

affected nerve chemically damages the nerve and interferes with its

function for up to three months. This temporary destruction of the

nerve prevents the affected muscle from contracting and allows the

person to feel more comfortable. The nerve block may also improve

gait and mobility. The injections of phenol are usually given by a

physiatrist or anesthesiologist using an JEMG to pinpoint the

location of the nerve.

On rare occasions, surgery is required to cut one particular nerve to

the affected muscle without endangering other nerves that are in

close proximity. This surgical procedure is permanent 1 and

irreversible. Fortunately, the recent availability of the baclofen

pump has greatly reduced the need for nerve blocks or surgery to

reduce spasticity.