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- [00:00]
A
Hi everyone. Thank you so much for tuning in today. About a month or so ago, I posted on social media about the topic of clonus in multiple sclerosis. And to my surprise, a lot of people didn't know what it was and they were hearing about it for the first time and there were tons of questions about it. And clonus is something that is actually pretty common in multiple sclerosis, or at the very least, it's very common in the people that I, I have treated with Ms. So I wanted to turn it into an episode for you and first explain what it is and how to fix it, because it's one of those rare symptoms in Ms. Where you actually can fix it. It's not something that is just here to stay forever. But then I'm also going to go into the questions that were asked about clonus because they were very specific questions about specific day to day activities where people notice that they experience clonus and they were wondering what to do in that specific situation. So I thought that could be helpful to review as well.
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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 platform. 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 read. Let's dive in.
- [02:11]
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The textbook definition of clonus is an abnormal reflex response to a muscle stretch that involves rhythmic movement. And we're going to break that down. So if that doesn't make sense to you, that's okay. But one way that you can think about this that happens in everyone, not just people with Ms. Or other neurological disorders, is the hiccups. Hiccups are actually a reflex that occurs due to an abnormal muscle stretch in our diaphragm. And this can happen in the legs, hands or face. But one way that I like to define clonus that I think makes a little bit more sense is an involuntary muscle spasm or tremor in the leg, hand or face. And I will say 98% of the time that I see clonus in my patients, patients, it's specifically in their leg. So that's what I'm going to be focusing on today. So when it happens in the leg and it's this involuntary muscle spasm. You might be able to imagine this. It looks like a muscle shaking. And if you're sitting, I'm assuming most of us are sitting right now. If you are sitting with your feet on the ground, if you had clonus, it would look like one of your legs or both. But usually it's just one side, not both. One of your legs would be bouncing sing. So it can look like a leg bounce or a leg shake. And the interesting thing is you might assume that clonus is occurring in the hip or thigh or in the knee, but in reality, it's actually happening from the ankle. And the reason that it's happening is because of the angle of your ankle. So the more flexed your ankle is, the more likely you are to get clonus to get this bouncing. So what I mean by more flexed your ankle is, is if you're sitting and your hips and your knees are at 90 degrees, so you're sitting in this theoretical ideal posture, but then you bend your knees. So if you bend your knees and move one or both legs back further, the angle of your ankle lessens because it's more flexed. There is less space between the top of your foot and your shin bone versus if you straighten your knee and you push your knee as straight as you can with your foot still staying flat on the ground, the angle really opens up. There's way more space between the top of your foot and your shin bone. So when clonus kicks in, typically it's when that angle is less. It's when there is less space between the top of the foot and your shin bone. So typically that means that it occurs when the knee is more bent. And this is really important to understand because it can occur when we are sitting, it can occur when we are exercising. And when it happens, when that angle is too little, the ankle will start to shake. It gets that reflex and that involuntary spasm. So the ankle starts to shake like that. And because the ankle is shaking, the rest of your leg also shakes. So a lot of people misconstrue clonus to actually be a hip symptom or a thigh or a knee symptom. But in reality, the leg is shaking like that because of the ankle symptom. And that symptom is, is clonus. There are two ways to determine if you have clonus. And for starters, you might be listening right now and thinking, oh, yeah, I definitely have that. Like, you know what I'm talking about, you know, when it happens for you. But you might also be thinking huh, I've never heard of this before. I don't know if I have clonus or not. So there's two ways that you can test this. One way is to do the movement that I just suggested, where you bend your knees so you're sitting, and you're bending your knees so that your heels go back as far as you can get them while still maintaining touching the ground. So you don't want your heels popping up off the ground. Your heels have to be touching the ground with your knees bent as far as they can go. That is about the lowest angle that you can get. Do you notice any bouncing in one or both of your legs? If not, then you may not experience clonus, at least not in this seated position. Another way that you can test, and this is actually how we test in the physical therapy clinic, is to be lying down so you are fully relaxed. And then you would have someone else grab the bottom of your ankle or bottom of your shin, maybe near your Achilles or slightly up above. So they're holding that, and then their other hand grabs the toes and the balls of your feet and they quickly push up towards you. And when they push up towards you, if you have clonus, it will bounce, it will push back into their hand. And that goes back to that definition that I mentioned earlier, that the reason that this is happening is because it's a reflex, an abnormal reflex in response to a muscle stretch. And when we're testing in that way, we're quickly stretching the Achilles to see what that flexibility is like. But when there's a neurological disorder or disease involved, like ms, clonus can happen. If when you quickly stretch that Achilles and you quickly push up towards you, someone else is pushing your toes towards your face and you don't notice any bouncing, then that means that you don't have clonus and you likely won't have it in other positions. So let's get to the good stuff, which is how to fix it, how to prevent it. And as I mentioned earlier, there is a way to fix and prevent this from happening. So the way to do that is to change the angle of your ankle. And usually what that means is to straighten your knee. If you remember the example I said earlier, the more we bend our knee and keep our feet flat on the ground, the shorter that angle is going to be, and that's going to promote more clonus, more leg bouncing. But if we straighten our leg, that angle really opens up and then it's more likely to reduce clowness. So if you are experiencing clonus, this Ankle shaking. That leads to leg shaking and bouncing. One really easy thing you can do, especially if you're sitting, is straighten your knee. Now, when you're straightening your knee again, remember, you want to keep your foot flat on the ground so you're not straightening it to the point where your heel is touching the floor and your toes are facing the ceiling. Your toes should still be touching the floor, as is your midfoot. And your heel, your knee is just a little bit straighter, so your foot is further away from you. Nine times out of 10, if not 9.9 times out of 10, when you change that angle, it will reduce, if not completely, get rid of Clonus. Now, Clonus typically isn't painful, but it can be fatiguing. I will never forget I was working as a physical therapist in the PT office and I had a physical therapy student that I was in charge of looking after in his training for about eight weeks. And I had him test one of my patients diagnosed with Ms. For Clonus. And so he grabbed the ankle, he grabbed the foot, he quickly stretched that Achilles and sure enough, there was Clonus. And he just thought that it was the coolest thing. And so he kept testing it over and over again and he kept holding it. So he would do the quick stretch and he'd hold it there and it'll keep bouncing until you release it. And my patient at one point was like, can you give me a little bit of a break here? This is very fatiguing. My ankle feels so tired right now. So the longer you stay in Clonus, the more likely it will feel fatigued. Typically it's not painful though, it's just more annoying than anything else. So I wanted to dive into four questions that I received about Clonus. And there were lots of questions that came in, but most of them can be answered with the answers that I will share in these four questions. So the first question was, how do you fix this if you are on a bike? This is a great question because sometimes you'll notice Clonus when you're sitting, just like we practiced. If you practiced with me here or other times, you'll notice it when you're moving. And specifically if you're on a machine that puts your ankle at a non ideal angle and the bike is one of those machines. And so typically if you are on a bike, this could be a stationary bike or a recumbent bike, even a stepper bike. The reason it's happening is the same as what we've just mentioned, which is the angle is too little. So the more you point your toes away from you, the less likely you will get clonus. Think about what we just talked about. The more you straighten your knee, the less likely that clonus will limit you. And come on. The reason for that is because the angle is more open. And if you were to straighten your knee and look down at your foot, your toes are almost pointed down. So when you're on a bike, one way that you can reduce clowness is to point your toes down the whole time. Now, if you are really into biking or spinning, you'll know that this is not correct form. But if you have Ms. And or another neurological disease, and if you're noticing clonus, then this can be a really quick and easy way to get rid of that bouncing. You might notice clonus from the very beginning, or you might just notice it more towards the end of your bike ride when you're getting a little bit more fatigued. So regardless of when it happens, you can implement that technique where you point your toes down towards the floor. Or if you're more on a seated bike, you'd point your toes away from you, so towards the wall or whatever is in front of you. That will open up that angle of your ankle and therefore reduce or completely get rid of clonus. The second question that I got was, how can I tell if the leg shaking is from anxiety or clonus? Which is a very valid question, because sometimes if we are feeling anxious, and especially if we're not even aware of how anxious we actually are, we'll bounce something, we'll bounce our leg, we'll bounce. Our arm will kind of shimmy. And that can be something that our body does automatically to kind of calm our nerves, calm our anxieties, but that's very different from clonus. And typically the way to determine if the reason that your leg is bouncing is due to clonus or anxiety or something else is to attempt the movement that we've been talking about, which reduces or eliminates clonus, which is straightening your knee. Open up that angle of your ankle. If you do that and the clonus reduces or lessens or eliminates, then it was clonus. It was just based on the angle that your ankle was in. But if it doesn't go away, then that's more likely a cause of something else, like anxiety. So the one great thing about clonus is not only that you can fix it by changing the angle, but you can quickly determine if what you're experiencing is clonus or if it's something else. And the way to do that is by straightening your knee, opening that angle and seeing what happens. Does it persist or not? If it does persist, but something else if it doesn't? Likely Clonus. The third question was when standing, for example, in the shower, when I reach for the shampoo at the floor, my leg can start to bounce. How do I stop that? So without seeing this person attempt this movement, it's a little bit hard to say exactly what's happening. But with the example that they gave where they are standing and they're reaching down for something on the floor, in this specific case, the shampoo, typically when we reach down, we bend our knees at least a little bit. Very rarely do we just hinge from our hips without bending our knees at all. When we bend our knees, the angle of our ankle lessens, which can promote clonus. And not only that, but in this specific situation, this person is in the shower. And if you are taking warmer showers, and if you are someone who has heat intolerance, then your clonus might kick in when you have another symptom already happening. As I mentioned earlier, if you're exercising, you might not notice clonus until the end of your exercise routine. The reason being you're more fatigued, you have this other symptom, which is fatigue, and then clonus kicks in. In this case, in the shower, it could be that you are experien experiencing even just a little bit of heat intolerance and then clonus kicks in. So that's one thing to consider. But also again, going back to the angle of our ankle, when we bend down to pick something up, we're likely bending our knees. And when you bend your knee, that angle lessens and that can cause clonus. So the way to fix this, if you can do this safely, because again, we're in the shower, it's going to be wet and slippery. But if you can do this safely, what you would do is whichever leg it's happening on, move that leg a little bit forward in front of you so you're more so in a staggered stance with one foot forward, one foot backwards, not in a tandem stance. I'm not asking you to put your foot one in front of the other, but just move one foot forward and then go ahead and bend down. And that foot that you're moving forward is the leg that you've clonus on. The reason this should work is the same reason that I've mentioned before, where when you're putting that leg in front of you, it opens the angle up. So even if you bend down to pick something up and that angle lessens because it's starting from a more open position, it likely won't cause clonus. The fourth question that I got was, does clonus only happen in multiple sclerosis? Because I have a decent amount of followers and even clients who don't have ms, but they do have other neurological symptoms. So I thought this was a really great question. And the quickest answer is no. This doesn't just happen in multiple sclerosis. It can happen in any neurological disease. And so of course that includes ms, but it can also occur in stroke, in a head trauma of any kind, meningitis, cerebral palsy, functional neurological disorder. Any type of neurological disorder can have this abnormal reflex that occurs in response to the muscle stretch. And again, it looks like this rhythmic movement, this bouncing or shaking. And it can happen in the legs, hands, or face. Most typically, as I mentioned earlier, with ms, I mostly see it in the legs. But yes, it can happen in other diagnoses that are neurological. And yes, it can happen in other body parts. If you are experiencing clonus in another body part, let's just say your hands or your arms, the way to reduce this would be very similar. Because, remember, the reason it's happening is because a specific muscle is being stretched. So we just relax that muscle by changing the angle. So if you notice it when you reach for something, if your arm extends or if your hand extends, then one way to reduce it is allow your hand or arm to relax and to bend. Or if it happens when you're bending your arm or bending your hand, we can extend it. So you would want to do the opposite action, because whatever action you did that caused. That caused a specific muscle or a group of muscles to stretch a little bit too much out of their comfort zone or at a speed that was out of their comfort zone. So that's the way that you would limit or reduce or eliminate clonus in any body part. I hope you found this helpful, and I hope it answered a lot of questions that you might have around clonus. If you do have clonus, and maybe you didn't even know you had it until right now, it's okay. It is one of those symptoms that we can alter based on the position of our body. So it's one of those nicer symptoms where we don't have to wait weeks or months or years for neuroplasticity to kick in. We can change the symptom right there on the spot just by changing the angle. So I hope you found this helpful. Thanks so much for tuning in. I will see you next time.
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Thank you.
- [20:16]
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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. 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 insider.
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That link will be shared in the
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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 tune in next week for another episode of the Missing Link podcast. RA.