Spasticity and spasms
Louise Jarrett, spasticity nurse specialist
Open Door - August 2008 pages 6-8
Spasticity and spasms are symptoms often associated with multiple sclerosis. This article aims to describe spasticity and spasms and unravel related terminology. It will begin to explore how spasticity and spasms can be managed and will be complimented by a subsequent article that details available drug treatments.
To ensure people with MS and health care 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, rather than a sharp contraction of a muscle. Unless the meaning of this word 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.
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.
Stiffness / increased resistance to movement
People with spasticity describe that their muscles feel stiff, heavy and are 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.
| Spasms | |
|---|---|
| Flexor spasms: The limb will bend upwards towards the person's body |
 |
| Extensor spasms: The limb extends away from the person's body |
 |
| Adductor spasms: The limb will pull 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 |
 |
(Figure 1: Different types of spasms. Adapted from Stevenson and Jarrett 2006)
Can spasticity and spasms be useful?
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 in transferring from bed to chair or to walk.
Why do these symptoms occur?
Nerve pathways connecting the brain, spinal cord and muscles work together to co-ordinate movements of the body. These pathways can be disrupted in multiple sclerosis and can lead to loss of co-ordination, overactivity and / or weakness of muscles.
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 is challenging to manage. 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. Health care professionals need to appreciate what the person is describing so that they can recommend appropriate treatments.
To assess whether the heaviness is from weakness or spasticity, it may be necessary for the health care professional to bend and straighten the limb. This is often described as moving the limb through its full range of motion. A limb will resist being moved if spasticity is present but if weakness is present it will move more easily, although a weak limb can still feel cumbersome and weighty to move for the handler.
Clonus
This is a repetitive, up and down movement, often of the feet; it is often observed as a constant tapping of a foot on wheelchair footplates. Individuals often find unique ways to minimise this symptom such as lifting the limb, or leaning forward in the chair to pass weight through the leg.
Other symptoms associated with spasticity can include fatigue and loss of dexterity.
What is tone?
Health care professionals may comment on the 'tone' in a person's limbs. Muscle tone is described as the resistance felt when an arm or leg is moved or stretched. Normal tone occurs when an individual is relaxed and the health care professional can bend and straighten the limb without difficulty. An increase in tone (an increase in resistance to movement) 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.
Managing spasticity and spasms
Managing spasticity and spasms is a balance between maintaining their usefulness and minimising the negative aspects within the context of a person's lifestyle.
Key principles of managing spasticity and Spasms
Key to any long-term management plan is the need for movement or stretching and the ongoing management of trigger factors.
Movement and / or stretching
It is important to keep muscles, ligaments and joints as flexible as possible. This can be done through stretching, active or passive movement. 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 (figure 2). This can be assisted by adapting equipment such as wheelchairs and using aids to promote sleep positions. Experts who can advise include specialist seating services, physiotherapists and occupational therapists.
| Optimising sitting postures | |
|---|---|
| Poor positioning in sitting: |
 |
| Good positioning in sitting: For example when in any chair if possible sit with your hips and bottom at the back of the seat, with your knees and feet at right angles |
 |
Figure 2: Optimising sitting postures. (Adapted from Stevenson and Jarrett 2006)
What can be done and who can help?
Increasing knowledge about spasticity and what trigger it can help people manage it more effectively and prevent symptoms. Whether symptoms are mild or severe, medical, physiotherapy, nursing and occupational therapy treatment, advice and education can help increase understanding of spasticity.
Certain factors are known to exacerbate spasticity and spasms; minimising their impact can reduce spasticity and spasms.
| Trigger factors | Who can give management advice |
|---|---|
|
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, bowels and skin. 'Pam noticed an increase in her spasms that coincided with her new pair of shoes causing a blister. Once the blister healed the spasms reduced.' 'Pat recognised that urinary tract infections really increased her spasms. Now at the mere hint of an infection, such as needing to pass urine more often or if it smells different, she is right on the phone to her GP or district nurse.' |
|
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. 'Bob experienced an increase in stiffness in his legs, his GP detected a cellulitus infection beginning in his lower leg.' |
|
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. 'Irene found that if her leg bag was secured too tightly it would aggravate her spasms.' |
(Figure 3: Trigger factors. Adapted from Stevenson and Jarrett 2006)
In summary, the ongoing need to incorporate movement, stretching and good sitting and lying postures together with managing trigger factors cannot be over emphasised in the management of spasticity and spasms. However, sometimes it is necessary to compliment these strategies with the use of drugs and this will be covered in an article in the next issue of Open Door.
Reference
Stevenson YL, Jarrett L (eds).
Spasticity management: a practical multidisiplinary guide.
Abingdon: Informa Healthcare; 2006
Join the Open Door mailing list to receive your own copy through the post (UK addresses only) or by email.
