Multiple Sclerosis Centers of Excellence
Managing Spasticity in Multiple Sclerosis
Spasticity is a common symptom of multiple sclerosis (MS) that affects many people at some point during the disease. It happens when damage to the brain or spinal cord disrupts the normal signals that tell muscles when to tighten and when to relax. Instead of working smoothly together, the muscles lose their normal rhythm. This can cause stiffness, tightness, involuntary movements, or a bouncing in the muscles called clonus.
For some people, spasticity begins as a feeling of stiffness after sitting for a long time or when waking up in the morning. It may ease up once you start moving around. Over time, though, the stiffness may become more constant. Spasticity can range from mild to severe. In mild cases, it may actually be helpful - providing some stability when getting in and out of a wheelchair or walking. But when it becomes more severe, it can cause pain, interfere with walking, make personal care difficult, and even lead to joint contractures or skin wounds if left untreated.
What Makes Spasticity Worse?
A sudden increase in spasticity often has an underlying trigger. Common triggers include urinary tract infections, skin wounds, and kidney or bladder stones. Before starting or changing treatment for spasticity, your health care provider may recommend a physical exam, blood or urine tests, or imaging to look for one of these triggers. Over time, many people learn to recognize the signs that something is making their spasticity flare up.
Treatment Options
There are many ways to treat spasticity, and the best approach often involves a combination of strategies. These treatments do not make muscles stronger, but they can make daily tasks much easier by controlling the overactive muscles.
Stretching
Stretching is the foundation of spasticity management and should be done daily. Muscles affected by spasticity tend to lose range of motion at the ends of their movement first, so it is important to take each affected muscle through its full range regularly. Prolonged stretches - held for at least 20 to 30 seconds - are the most effective. For mild spasticity, stretching alone may be enough. Even when other treatments are added, stretching should always continue.
A physical or occupational therapist can help set up a stretching program and may also provide splints for a longer-lasting stretch. Therapists can also use techniques like ice, vibration, or electrical stimulation to help calm spasticity before stretching. These methods have been used for decades, are safe, have few side effects, and can often be done at home.
Oral Medications
When stretching alone is not enough, oral medications can provide longer-lasting relief. The most commonly used are baclofen and tizanidine. Other options include gabapentin, diazepam, clonidine, and dantrolene. These medications work by relaxing overactive muscles and are generally well tolerated. Because they affect the entire body, side effects such as drowsiness or weakness can occur. Most are taken multiple times a day.
Injections
When spasticity affects only a few specific muscles rather than the whole body, injections may be a good option. Botulinum toxin (Botox), phenol, or alcohol can be injected directly into the overactive muscles to block the nerve signals causing the tightness. One round of injections can last several months, and because the treatment is targeted, it avoids many of the whole-body side effects of oral medications. The main trade-off is that injections weaken the treated muscles, which could affect activities that use those muscles. If an injection is not helpful, it takes a few months to wear off, so a thorough discussion with your provider beforehand is important.
Intrathecal Baclofen (ITB) Pump
When spasticity affects a large area of the body - particularly the legs - and other treatments have not been enough, an intrathecal baclofen pump may be an option. This device is surgically placed under the skin of the abdomen by a neurosurgeon. A thin tube connects the pump to the spinal canal, delivering liquid baclofen directly to the area around the spinal cord. Because the medication goes right where it is needed, the pump uses up to 100 times less medication than oral baclofen to get the same effect, which means fewer side effects like drowsiness.
Before getting a pump, most people go through a screening test. A small dose of baclofen is injected into the spinal canal through a lumbar puncture to see if the medication is effective for you. During the test, your legs may become temporarily weak, but this goes away within four to eight hours. If the test is positive, you and your doctor can decide whether to move forward with the surgery.
Once the pump is in place, the dose can be adjusted in your doctor’s office - for example, more medication at night to control spasms that cause waking, and less during the day when you are active. The pump holds enough medication to last one to six months between refills, and the battery lasts about seven years before the pump needs to be replaced.
The pump does require ongoing management, including regular clinic visits for refills and dose adjustments. There are rare but serious risks, including baclofen overdose or withdrawal. Warning signs of overdose include unusual drowsiness, difficulty breathing, or loss of consciousness. Warning signs of withdrawal include a sudden return of spasticity, itching, or low blood pressure. If you experience these symptoms, seek immediate medical care.
Getting Started
If you think spasticity is affecting your daily life, talk to your health care provider. Physical and occupational therapists familiar with MS can help identify the right stretches, recommend activity changes, and work with you to stay as active and involved as possible. Neurologists and rehabilitation doctors can evaluate whether medications, injections, or a baclofen pump might help. The best outcomes happen when spasticity is recognized and addressed early, and when patients and providers work together on a treatment plan.
Based on articles by Ileana Howard, MD; Daniel Pierce, MD; Kathleen Burgess, MD, MS; and Cinda Hugos, MS, PT.
