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The big question is, how does someone with Ms. Actually improve their mobility, strength, energy independence? The list goes on. My name is Dr. Gretchen Holley, physical therapist and multiple sclerosis specialist. Welcome to the Missing Link podcast. Tune in as I share the top strategies and exercises to help you gain control over your life with Ms. Using research driven insights and advice from top industry experts. Whether you're newly diagnosed or have had Ms. For over 30 years, whether you have relapsing Ms. Or progressive MS, this podcast is for you. You're sure to feel empowered and inspired after each episode. Ready? Let's dive in. Foreign.
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Hello everyone and Welcome. I am Dr. Gretchen Holley, a physical therapist and multiple sclerosis certified specialist. Which is basically just a mouthful way of saying that I specialize in helping people with Ms. Learn exercises and strategies and techniques, ways to do things to not just get stronger and improve your balance, but also make your daily activities feel easier and less overwhelming, less cumbersome. Spasticity is such a common symptom and it's often misunderstood and there's several things that we can do to reduce it and manage it. So we're going to be going through a lot of that information today. We're going to be talking about things like why it happens, what triggers it, and perhaps most importantly, or what you might be most interested in is how to manage it. So we're going to touch on each of those things and then at the end I want to overview on just what newest research is showing. Because spasticity can be very debilitating and limiting and it can affect us in our daily lives in so, so many ways. And therefore there are researchers out there trying to find solutions to reduce it. And so I wanted to share that with you so that you feel up to date on what is happening in spasticity research specifically for multiple sclerosis. Spasticity is very common. It is, in my opinion, one of the most common symptoms that people with multiple sclerosis experience feel. Fatigue is probably the number one. But spasticity is up there and up to 84% of people living with Ms. Have some form of spasticity. And in a second here I'll get into the different levels of spasticity so you can see what the variability is. Spasticity, while it might just sound like a simple symptom, you know, maybe you think of it as muscle tightness, it's often one of the main symptoms of Ms. That can lead to lack of self confidence or frustration or decline in self image or decline in quality of life. Because it can impact us so much. And the cause of spasticity can either be primary or secondary or a combination of both. And let me take a step back here and say any symptom of Ms. Can be primary, secondary, or a combination of both. And what I mean by that is primary symptoms are symptoms that are caused directly from the disease process of multiple sclerosis, whereas secondary symptoms are symptoms that are caused from something else. Maybe fatigue, because you didn't get a good night's sleep, maybe a uti, maybe stress. When we're talking specifically about spasticity, though, some of the most common reasons for secondary spasticity is fatigue. So if you're more fatigued, then your muscles might get tighter. Additionally, weakness, if you have weakness in certain muscles, then that can make other muscles tighter. Difficulty balancing, again, it makes other muscles tighten up and work harder. So that can cause spasticity and pain as well. If we are in pain, we tend to withdraw and tighten just to protect our bodies, or at least that's what our body is trying to do. But it actually just makes symptoms like spasticity worse. I want to clear up a few definitions, because not all muscle tightness or spirit spasms or cramps are spasticity. So, first and foremost, a muscle spasm is generally when a muscle involuntarily contracts, but then it relaxes. And then a muscle cramp is the same as a spasm. It contracts involuntarily. You didn't mean for it to contract. And then it relaxes. But the contraction, the tightening, tends to last longer. Whereas spasticity is when a muscle stiffens or tightens and it prevents or restricts normal fluid movement. And as a physical therapist, I mostly see this and work on this in people with Ms. As it relates to your gait, your walking. But it can affect any muscle, meaning it can affect your speech, it can affect your swallowing, it can affect your upper body. It can affect any muscle in our body. And the reason that this happens when it's caused from multiple sclerosis. So that primary symptom is an imbalance of electrical signals from the brain and the spinal cord. So it's not necessarily that something's wrong with the muscle itself. It's that pathway, that connection between the brain and the spinal cord and the specific muscle that we are experiencing this spasticity and tightness in. So I want to review with you something called the Modified Ashworth Scale. It ranges from 0 to 4. And while this has been around for a very long time, at this time, it's one of the best ways that clinicians use to rate spasticity internally, just so they know amongst each other what level you are at. So zero means no increase in muscle tone, meaning you do not have spasticity. A score of a 1 means that you have a slight increase in muscle tone, and it's manifested by what we call a catch and release or minimal resistance at the end of the range of motion. So if with my arm, I. I am trying to. Let's say I'm trying to bend my elbow. If I'm. If someone is holding onto my arm and trying to bend my elbow to see how much resistance or range of motion I have, then they would mostly be able to bend it pretty freely. But at some point it would catch and then they would be able to release it. So it's like it. I can't think of better ways to explain it other than a catch or it gets caught and then it releases and can go pretty much the full range of motion. Once you get past that catch, then a grade of one plus is again, you get a little bit of a catch. The rest of the amount of movement, while it might still be there, you have resistance the whole way. So it's no longer just a catch and then easy to get past that catch. It's a catch, and then you have resistance the rest of the way. And oftentimes if you have a grade of one plus, you cannot get your full range of motion, your full amount of bending or straightening or whatever muscle it is that you're trying to use. Next is a score of 2. A score of 2 is just more marked increase in muscle tone throughout most of the range of motion. However, you can still move the muscle, you can still move the joint. So a score of two, you don't necessarily get that catch and release anymore. It's just tightness throughout the whole time that you're trying to bend or straighten or move whatever muscle you're working on. Then we've got a score of 3, which is considerable increase in muscle tone and passive movement, meaning someone else trying to move you is very difficult. So oftentimes with a three, the clinician, your physical therapist, your neurologist, whoever you're working with who's trying to bend or straighten your arm or your leg or whatever it might be, they're having a pretty difficult time trying to bend it, and they are not able to fully bend it. And then a grade of 4 is considered rigidity, meaning it's stuck. And the way that rigidity was explained to me back in the day was essentially that the hulk, the strongest person could not come and bend that elbow or bend that knee or straighten it, whatever it is. It's not a strength it issue. So someone who's really strong wouldn't even be able to do it. The muscles are just rigid and not going to move and that joint is contracted. So as you can see, it's grade zero through four with a one plus thrown in there. But that's a big difference. Zero is no increased tone at all, no increased tightness. And four is the hulk can't even move you. So there's, there is a lot of wiggle room. But this can help your providers, your neurologists, whoever you're working with, try to decide what might be the best course of action for you. Spasticity is not just neurological, as I mentioned, it can be. That's the primary symptom where it is related to the neurological connection between our brain, our spinal cord and the muscle. But when it is neurological, we call that sometimes neuronal or it's nervous system driven. And this is when it's caused from lesions in the brain or spinal cord. It can cause increased reflexes or reflex activity. And oftentimes this type of spasticity is velocity dependent, meaning speed dependent. So if you have ever been walking and let's say you have spasticity in your leg, maybe it's really hard to bend your knee or straighten your knee and as you walk faster it's even harder because your spasticity, your tightness kicks in more. That's more of this nervous system driven spasticity. But the other type is non neuronal or non nervous system. And this includes things like our muscles and our soft tissue changes. So it's things like muscle shortening or muscle contractures and increased connective tissue tightness. So that's the tissue that's underneath our skin and on top of our muscles. Decreased ability for our muscles to stretch like they used to be able to. Fat infiltration, muscle atrophy, all of these muscular and soft tissue type things, our fascia, they can also contribute to spasticity. And over time stiffness may come from both of these or it is possible that you only ever experience it from one of them. And this matters. It might sound a little too in depth, but I do think it matters to understand where it's coming from because it can significantly help with the solutions that you implement. Because oftentimes stretching alone is not going to be enough and stretching will really hope only help. One of the two types or positioning and strengthening, strengthening and orthotics and some other solutions we'll talk about in a bit here. Those might be more of a better solution or a combination approach that are often forgot about, but can be just as helpful. And over time, untreated stiffness and spasticity can become what we call a contracture or a structural limitation, meaning that grade four, meaning it just doesn't move. So we want to do everything we can in order to prevent it from getting that far. So one thing I'm constantly helping my Missing link members and clients that I'm working with with Ms. Understand and brainstorm is the question of is it spasticity or is it something else? And so there's a few questions that you can ask yourself to determine this. So number one, does your muscle or joint or whatever body part that you feel you have spasticity in, does that feel tight all day or just off and on? If it's tight all day, then it might be more likely to be spasticity versus if it's off and on, it could just be some muscle stiffness, off tissue, a little bit of tone here and there, but might not be full blown spasticity. The second question is, are you experiencing sudden kicking or jerking or these spasms? If so, that might be more of a muscle spasm, which also can be neurological, but it might not necessarily be your classic typical spasticity. The third question is, is it worse with anything specific? Is it worse at night? Is it worse with infection? Is it worse when you're stressed? If so, it likely, it still could be spasticity, but it's more of that secondary spasticity where the reason is because of something else. So if we address that reason, the spasticity or tightness can go away. It might also not be spasticity when it's caused by something else. So it could go either way with that one. And then the last question, and this was an important one, that's a really easy differentiator, is does it only hurt or is it only limited at your end range or when fully stretched? And what I mean by that is, can you fully move that joint? So in my example from earlier, can you fully bend your elbow? If you cannot, you can't get to that, what we call end range, you can't fully stretch in that direction. Then that is you usually some form of spasticity or a level of muscle tightness where that muscle is shortened or that joint is restricted. It might be more of an orthopedic issue where something's wrong with the joint itself. So not all tightness is the same, not all spasticity feels the same, and not all tightness or spasticity has the same treatment. It's very individualized based on what it feels like for you when it's kicking in. But these are some questions that you could start asking yourself and then share your answers to these questions with your neurologist when you're talking about spasticity. Spasticity can be triggered by lots of different things in addition to any Ms. Symptom. But specifically when we're talking about spasticity, it can be triggered by things like any type of infection. The most common one that goes unnoticed is a urinary tract infection. So a UTI constipation can trigger spasticity, skin breakdown, ingrown toenails, even tight clothing or braces, pain or an injury, stress, fatigue, heat, cold. There's so many things that can cause any symptom to worsen, and that goes for spasticity as well. And the reason why I like to mention this is because it's really important to look for triggers, especially with some of those questions that we were talking about. If it feels worse at night, why? If there's sudden jerking at specific times, why? And is it because you're more stressed at that time, or is it because it's a hotter or colder time of day and that's what bothers you? Was it just on the days that you may have been constipated? And if we can figure out what some triggers are before we jump to a medication or another treatment option, then it can be a more effective way to treat this spasticity. So when it comes to treatment for tightness and cramps, not necessarily spasticity, we'll get there in a second. But for tightness and cramps, things like muscle stretching, staying hydrated, exercising and moving regularly, improving nutrition, specifically protein and magnesium can be really helpful. And then topical analgesics. So things like Arnica, Icy hot tiger balm, etc. These sound like just your typical advice, but they really can be effective for general muscle tightness, spasms, cramps, etc. One thing that I do want to add that applies to tightness and cramps as well as spasticity is muscle stretching. I mentioned that a second ago, but it's so important that you stretch the specific muscles that are tight or the specific muscles that are spastic or cramping. I always like to share this story because I think it paints such a strong picture of what happens with a Lot of people with ms, which is I was working with one of my patients in her home. I love doing home visits when possible. And she has Ms. And she said, Dr. Gretchen, my quads are so tight, and I don't understand why, because I truly stretch all day long. And I said, okay, let's brainstorm this. What stretches are you doing? And she honestly listed maybe 10. I can't even remember now, but it was a lot. Maybe seven to ten different stretches. And she's like, I'm doing them in the morning, afternoon in the evening, and, you know, this is how long I'm holding them for. Like, she knew her stuff. But what I noticed immediately is that of all the stretches that she mentioned, not one of them were for the quad muscles. And that's the muscle that she felt this spasticity in. So of course her specific spasticity is not going to feel any better. Because even though she's stretching, which is great for lots of other things and can sometimes help with spasticity, if you're not stretching the specific muscle that's tight and spastic, then you're not going to see that big of a difference. So when we are switching gears to treatment for spasticity, there's lots of different options. Not all of these are going to be appropriate for every person with spasticity. It's going to depend on what grade you're at, 0 to 4 of that modified Ashworth scale. But also things like, what does it feel like to you? How is it limiting your day? If it is limiting your day, and it's very individualized. But generally speaking, treatment for spasticity, one of the first things typically is physical therapy and or occupational therapy. This is where you'll learn specific stretches. If it's more intense, if it's more of the grade three or grade four, you might get some splinting or casts from an occupational therapist. Other treatments for spasticity are medications. There's several. The ones that I have seen most often just from my Missing Link members and people with Ms. That I talk to are Baclofen, Tizanidine, benzodiazepine, and Botox injections. One thing that's important to know about all of these is that they may cause muscle weakness. But what I really mean by that is it's not that they cause muscle weakness. It's that it reveals what strength you do or don't have when that spasticity isn't around. And physical therapy with this passive stretching, even things like massage that can happen with those forms of treatments as well, Meaning you could go to a physical therapy session and they get you nice and loose, they stretched you, they massaged you, they did all the things to lessen your spasticity. And you go home and you feel like your legs are super wobbly and unbalanced and coordinated. And it's because sometimes spasticity, while it does restrict us, it's actually what's keeping us standing upright. Because without that spasticity, our muscles aren't strong enough to keep us upright. And so sometimes the goal is not to fully get rid of spasticity. We actually want to keep some of that spasticity around, whereas other times we might be wanting to get rid of a lot more of it. So, again, it's individualized for each person. But it's important to know that that exists, because if you're not expecting that and then it happens, it can almost feel like, oh, my gosh, this baclofen caused me to get weaker, or this botox injection caused me to get weaker. And it's not necessarily the case. That's not the full picture. The benzodiazepines, according to what I've seen in research, does tend to be best for more of nocturnal spasms. So nighttime spasms, which can be common in ms, Tizanidine is sometimes associated with more fatigue than Baclofen. But every person is going to respond differently to every medication. It would be best to talk to your neurologist about all the different options. Modafinil is another good one for fatigue. Again, there's so many, so let's talk to your health care provider and see might work best for you. And then last but not least, while this is typically the last considered, is surgery. So things like an intrathecal baclofen pump, which consistently pumps out baclofen. It's an internal pump that you wear 24. 7. A rhizotomy is when a surgeon will cut away part of this spinal nerve. This is not seen as frequently in multiple sclerosis, but it is seen every now and then. And then a tenotomy is when the tendon is released. So, and this actually is pretty common with carpal tunnel syndrome, where there's a lot of tightness here and you might be getting that numbness tingling in your hand. The surgery for that is quite literally they make an incision and they make a tiny little snip in the tendon to release the tension in the tendon, and that can significantly help with reducing the tightness there. So that sometimes is done as well for Ms. Related spasticity. There's also newer research really over the last several years, but more and more is coming out slowly but surely around cannabis for spasticity. And cannabis research is a tough one because it's constantly being challenged by legal issues. There's so many different ways to have cannabis that it can be hard to hone in on one way. Inhaled, inhaled cannabis can negatively affect cognition. There's salves that creams that you can put on with for cbd. There's no regulation really of how much CBD versus thc. So there's so many different components and variability when it comes to cannabis research. However, components include THC, which is a psychoactive component that may help with nausea or vomiting, and CBD is the component that might help with neuropathic pain. So again we have a whole other talk on pain, but the pain specifically from our nerves and the signals and misfiring CBD can also help with spasticity. I've had several of my missing link members use some form of CBD for spasticity and felt that it was helpful. According to research, Sativex or Nabiximals which is a combination of THC and CBD have been found to be helpful. It's been approved in Canada and Europe for Ms. Spasticity and Ms. Pain and evidence supports it as an add on for Ms. Spasticity treatment, not just on its own. And one thing that was important I thought to share as well from this research is that it improved patient reported spasticity but not necessarily clinician reported. Meaning if we go back to that modified Ashworth scale and I graded you a 2, then you went through this trial with doing Sativex or Naviximals, then you came out of that trial feeling like, wow, my spasticity does feel better. Whereas I would have still rated you a 2. But at the end of the day you are the one with the spasticity. If you feel like something is helping, that is way more important than what any clinician is might be testing. Side effects included dizziness, fatigue and specifically when it was inhaled, more of the cognitive changes. In an ideal world it would this treatment would be more CBD than thc. Really. We're trying to get like trace amounts of thc. This CBD is really the component that seems to be helping the most. And then Ketamine used for acute chronic pain and mood disorders. Types of stretching. So stretching can help with both types of spasticity that we've been discussing that neuronal type as well as non neuronal. But the goal and technique might differ. Not all stretching is created equal. There is active stretching, which means you are stretching on your own. No one else is touching you, no one else is is helping you. You're just doing a stretch on your own. Passive means that someone is is helping you. And there's actually two different forms of this. One is technically called active assisted, meaning you are stretching, you're doing something, but I'm helping you stretch a little bit further. Whereas passive is completely assisted. You are just relaxed. You might be lying on your couch and someone's lifting your leg up to stretch your hamstrings. Static is a type of stretch where it's longer holds. It can be anywhere from 30 seconds or so up to several minutes, which can be called prolonged static dynamic is shorter holds, that's only maybe three seconds and then you release the stretch and then hold for another three seconds and release the stretch. PNF stretching or proprioceptive neuromuscular facilitation is at an angle and it's with resistance. So it adds different components. And that's just a few. There's probably more. So as you can see, there's lots of different types of stretching. And to make things even more complicated, not only can one person prefer one type over another and feel better after one type versus another, but every muscle group is different. So even one individual could experience a situation where their hamstring feels so much more relaxed and less spastic after prolonged static stretching. But their hip flexors do a whole lot better after dynamic stretching. So it's just important to know that all of these exist. And you know, if, if you have felt like stretching has not helped you and you know you're stretching the right muscles, then it might not be that stretching is not helping. It might just be that you have to try a different type. Generally speaking, slow sustained stretching. So more of that prolonged static where you are holding for three minutes, five minutes, seven minutes, that does tend to calm neuronal. So that nerve based tone more than shorter stretches and longer holds may also address the soft tissue or fascia connective tissue shortening as well. So you are likely wondering right now, well what the heck do I do? Because that's a lot of different types. I would try a mix of dynamic, a mix of seated, a mix of the prolonged or active and see what feels best for you. There's so much research on the different types of stretching and not one will say this is the best one. It's so individualized. For each person and for each muscle group. So try them and see what does best for you. I also just want to add that so many people will tell me that they stretch all the time because they do yoga. First of all, yoga is actually a lot of balance training and strength training as well. But even if you're doing a yin yoga, which is more stretching based, yoga is a very active form of stretching. So if we go back and think about those different types of stretching, that's just one type. So if you're doing yoga and you feel like, like I'm doing yoga, this should be helping. Why are my muscles not relaxing? Try a different type. Again. It's not that yoga isn't good for you. It's not that yoga is not working, it's just not releasing the muscles in the way that you need them to. So trying a different way can work. Some of the muscles that tend to become spastic most often in multiple sclerosis are your elbow flexors. So this is bending your elbow. So if the muscles that bend your elbow are spastic, what that means is it's going to be difficult to straighten your arm. Hip flexors are another big one as well. If you have tightness in your hip flexors, it can cause a hinged posture where your butt is poking out back and your shoulders are forward. Your hip adductors or your inner thighs are other ones. And this can cause your knees kissing. Knee kissing can be what it's called. Or when you're, when one or both knees cave inward, that can be due to hip adductor spasticity. Your hamstrings or your knee flexors, the muscles that bend your knee, that those muscles can be spastic, which would mean it would be difficult to straighten your knee. Whereas on the contrary, your quadricep muscles are also really common to be spastic. And that's the opposite that those muscles straighten your knees. So if you have spasticity in those muscles in the quadriceps, it's going to be difficult for you to bend your knee. And then last but not least is ankle plantar flexors. So you're basically your calf muscles. And if your calf muscles are tight, it will pull your toes down and your heel up and it essentially puts you in the exact position that is foot drop. So when should you escalate care? When should you stop trying to just do things on your own and not take spasticity seriously? Because a lot of people don't, they just chalk it up to Ms. It is what it is, but it's really important to consider asking for a referral to a physical therapist or an occupational therapist or even a pain clinic if you have pain caused from your spasticity, if your spasticity is limiting your mobility or your safety, if it's interfering with your sleep. Because if you're not getting good sleep, it can make tons of things worse, if it's making caregiving difficult, if your conservative treatments that you've tried thus far are not helping, and if your pain is increasing. I was recently at an Ms. Conference where spasticity was one of the main topics and it was sharing how many people tend to not get the right type of care early enough for spasticity. And it was essentially saying that the earlier you can get care and strategies that help your specific situation, the better because there's going to be more options at that point. And spasticity management often works best with that team approach, that multidisciplinary approach. So physical therapy and occupational therapy and physiatry and your neurologist and an orthotist. Not that you need to do all those all at once, that sounds like a full time job, but oftentimes it is best to have that combination approach. Moving on to the research that I mentioned earlier that I wanted to share with you, there is some promising results. It's definitely mixed. Overall. These things I'm about to mention have been shown in research to be best used as additions to help with your spasticity management, not replacement. So if you're already on asbestos, the medication, then you could stay on that and then possibly if these become actually approved. This is not FDA approved yet or anything like that, but if research continues to show these being effective, it would be in addition to. So as I mentioned earlier, nabiximals or any, any combination of the cbd, THC are those are still being looked at in research. Another one is transcranial magnetic stimulation. Others is direct current stimulation. Others is transcutaneous electrical neural stimulation, also known as tens. Another is FES or functional electrical stimulation. So as you can see, lots and lots of research being done specifically on electrical stimulation to some part of of your body and in different ways. Direct current is different from tens, which is different from fes. With fes, it's more that you're wearing the electrodes and they're stimulating your nerves while you're moving, whereas with tens you're usually just sitting. And TENS is more for pain management. Other things that are currently being researched for spasticity is vibration therapy, cryotherapy or thermotherapy and neurorobact robotics. So these, for the most part, all of these are non pharmacological options and they are showing promising results. As I said, they are mixed. Generally speaking, they're showing mixed to moderate benefits and again, best used as an adjunct within a structured plan, not on its own. So all in all, there's so much that is best disease. It's not, unfortunately, it's not just as simple as tight muscles. It's so much more than that. But oftentimes there is a cause, whether it is multiple sclerosis or a secondary component, a secondary symptom. And so if we can focus on treating the cause or the trigger, then that can be a really great first step to seeing what is going to help you the most with your spasticity. Again, TENS is a specific type of electrical stimulation that tends to be more for pain than it is with muscle tightness. But that's not to say that it wouldn't help with spasticity, it just typically is more for pain. Thank you so so much as always for tuning in. Bye everyone.
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Thank you for listening to today's show.
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I am so grateful to have you as a listener.
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If you'd like extra resources, such as a video of one of my seated exercise classes, my favorite core exercises, and the opportunity to ask me your questions, head to missinglink.com that link will be shared in the show notes along with links to my social media handles. If you loved this episode and think a friend or family member with Ms. Would benefit from listening, please go ahead and text or email this podcast to them right now. Sharing this podcast will help me educate and empower as many Ms. Warriors as possible. Thanks again for joining and be sure to subscribe. Tune in next week for another episode of the Missing Link podcast.