The holistic health and spirituality teacher tries to engage in physical exercise — mostly yoga and light weight training at the gym — every day to help manage her symptoms. Still, she says, “You never know how your day is going to be. Some days, I wake up and feel great and can’t wait to get to the gym. Then there are other days I fall as soon as I get out of bed, either because of the pain or because I just don’t have the strength in my legs.” The symptoms of muscle weakness and pain Ciganovich experiences can be traced to one of the hallmark symptoms of multiple sclerosis: spasticity.
What Is Spasticity?
The definition of spasticity reads like a description from a medical school textbook, but the National Multiple Sclerosis Society (NMSS) calls it a “feeling of stiffness” as well as “involuntary muscle spasms” or “sustained muscle contractions or sudden movements.” These symptoms may be as mild as simple muscle tightness, but they may become severe enough to produce painful muscle spasms as well as pain and stiffness in and around the joints. Spasticity has been estimated to affect anywhere from 30 to 80 percent of people with MS. It most often impacts the legs in those with MS, often producing problems with balance and strength. Still, the degree of spasticity, the muscles involved, and the resulting impairments vary from person to person, according to Alexius Enrique G. Sandoval, MD, medical director of the Multiple Sclerosis Rehabilitation Program at Johns Hopkins Medicine in Baltimore. “There often is an associated jerking of the limb as well,” Dr. Sandoval adds. “People often say they feel as ‘stiff as a board,’ and this interferes with their activities of daily living, affecting their ability to sit, stand, or walk.” The two most common types of spasticity in MS are flexor spasticity and extensor spasticity, according to the NMSS. Flexor spasticity may involve the hamstrings, which are the muscles on the backs of your upper legs, or the hip flexors, which are the muscles in the fronts of your upper thighs. People experiencing flexor spasticity may notice that their hips and knees seem stuck in a bent position and are difficult to straighten. Extensor spasticity, on the other hand, can affect the muscles on the fronts (quadriceps) and insides (adductors) of your upper legs, effectively forcing the hips and knees to remain straight, with “the legs very close together or crossed over at the ankles,” the NMSS says.
Managing Spasticity: Stretching, Medication, CBD
A number of steps can be taken to address spasticity and limit its debilitating effects. In fact, the NMSS notes that it’s important to treat spasticity proactively to avoid certain complications, such as contractures (frozen or unmovable joints) and pressure sores, in which skin becomes irritated, sensitive, and even damaged after extremities are left in the same position for too long.
Stretching
According to Sandoval, a regimen of regular stretching of your arms and legs is probably the most important treatment for spasticity. “In cases of mild spasticity, that may be all that you need,” he says. But if spasticity or other symptoms make it difficult to stretch your muscles on your own, he recommends working with a physical therapist or health aid. “Your spouse or a family member can also help,” he notes. For Ciganovich, exercising and stretching every day has kept her spasticity under control. “There are a lot of days I don’t feel like going to the gym, but I push myself,” she says. “I always feel better when I do my stretching and exercise, and even on the worst days, my MS symptoms practically disappear.”
Muscle Relaxants
In cases of moderate to severe spasticity, your doctor may prescribe a muscle relaxant, a drug designed to loosen tightened muscles. Most often with MS, the drug baclofen is used for this purpose. Baclofen is usually administered in pill form, but a small percentage of people with MS may need to have a baclofen pump surgically implanted. The pump, which is shaped like a hockey puck and is implanted in the abdomen, is designed to deliver the drug via a catheter to the spinal cord. “Baclofen has significant side effects, which can limit its effectiveness,” Sandoval says. “It can make you sleepy or groggy, which could be a problem if you have to drive or go to work, and in some cases it has been known to make people nauseated. The baclofen pump greatly minimizes those side effects because it delivers the drug directly to the spinal fluid that surrounds the spinal cord. However, inserting the pump is an invasive procedure.”
Botox
Your doctor may also recommend Botox (onabotulinumtoxinA) injections to specific muscles. These injections temporarily weaken the spastic muscle, which allows some improvement of function and reduction of painful spasms. “I recently started getting Botox injections in my neck and shoulder areas to manage the pain,” notes Ciganovich. “However, when the muscles are treated with the Botox, it makes it harder to work out. So I try and fight the pain and keep going.”
Cannibidiol (CBD)
There are currently no CBD-based medicines for spasticity approved by the U.S. Food and Drug Administration (FDA). Nonetheless, as more and more U.S. states pass laws allowing for the use of cannabis and its pharmaceutical derivatives for medical purposes, researchers are investigating its potential uses in MS, specifically for the management of symptoms like pain and spasticity. An example of a CBD already being used to treat these symptoms in MS is Sativex (nabiximols), a cannabinoid spray approved in Canada and some European countries for use as a complement to prescription medication. Sativex spray combines two chemicals found in many cannabis plants — CBD and tetrahydrocannabinol (THC) — to treat spasticity by working to balance out receptors found in multiple organs and tissues throughout the body. A review of existing research published in February 2018 in the journal Current Neurology and Neuroscience Reports found that of 10 “moderate to high quality” clinical trials, five “concluded that there was sufficient evidence that cannabinoids may be effective for symptoms of pain and/or spasticity in MS.” In addition, a study published in November 2016 in the journal European Neurology found that among 281 people with MS spasticity who used the Sativex spray for three months (at a mean dosage of six sprays per day) spasticity and spasticity-related symptoms (muscle spasms, fatigue, pain, sleep quality, and bladder dysfunction) were significantly improved. CBD is also available in oils and lotions for topical (on the skin) applications. “I have tried the CBD oils and creams for my legs and it seems to work,” Ciganovich says. “I think any type of treatment for MS should be allowed if it works for that person, because MS is difficult to live with and there’s no cure.” “In general, the data on the use of CBD and other forms of marijuana to treat symptoms like spasticity is limited and very mixed,” adds Vijayshree Yadav, MD, clinical director of the Multiple Sclerosis Center at Oregon Health and Science University in Portland, who published her own review in March 2014 in the journal Neurology on the topic. “And much of what we have is subjective — meaning it’s based on people self-reporting improvement in symptoms — as opposed to measurable, objective criteria. We are seeing more and more people experimenting with marijuana and its derivatives, but not everyone is seeing benefit.” As with any potential new treatment, Dr. Yadav recommends talking to your doctor before trying CBD or other marijuana-based products.
