Posted by: Thixia | October 26, 2008

Spasticity in MS 7 of 9



Rehabilitation can offer guidance and therapy to reduce spasticity and prevent muscle contractures and joint stiffness.  However, a multi-dimensional evaluation must be performed to investigate the interplay between spasticity and functional mobility before selecting the best rehabilitation approach.  Rehabilitation interventions can then be used alongside pharmacological and neurosurgical treatments. 


A stretching or exercise class may help provide social support



 and spasticity 


Many survey studies and anecdotal reports suggest that some people with MS self-medicate with marijuana (or cannabis, Latin name: Cannabis sativa) in order to relieve their spasticity.  Experimental pharmacological studies support the hypothesis that cannabinoid chemicals within cannabis, such as delta-9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD), exert muscle relaxant effects. 


While delta-9-THC does this via a specific cannabinoid receptor (the CB1 receptor) which was discovered in the central nervous system in the late 1980’s, CBD appears to have more complicated actions and may affect cytokines (proteins that are released by cells of the immune system and play a role in the generation of an immune response). 


Initial clinical trial data did not support the efficacy of delta-9-THC in reducing spasticity.  The first report from the “Cannabinoids in Multiple Sclerosis” (CAMS) trial, a blind and placebo-controlled trial in the UK, suggested that delta-9-THC had no statistically significant effect on spasticity when evaluated by the objective Ashworth scale.  However, in a 12-month follow-up study involving 630 patients, delta-9-THC was shown to have a small but significant effect. 


Nonetheless, in both studies the patients reported a subjective improvement in spasticity.  It is a matter of some controversy whether the initial lack of effect using the Ashworth scale reflects the lack of sensitivity of that scale for quantifying spasticity. 


The natural cannabis extract in the pharmaceutical product marketed as Sativex® has been reported to alleviate spasticity in a number of clinical trials.  Sativex is a 1:1 ratio of delta-9-THC and CBD and can be administered as a sublingual (under the tongue) or oromucosal (nasal) spray.  Not all trials testing the efficacy of Sativex® have been blind or placebo-controlled, raising questions about the quality of the data collected. 


Most trials that have been well controlled have still found a significant improvement in spasticity, at least according to subjective rating scales, however there is also some contradictory evidence regarding this. 


The most common adverse side effects reported have been

  • oral pain,
  • dizziness,
  • diarrhoea and
  • nausea. 


Of the other cannabinoids that have been investigated, the synthetic cannabinoid, nabilone, has been reported to reduce pain related to spasticity in one recent study. 


There have now been more than 12 clinical trials published on the effects of cannabinoids on spasticity and pain in MS.  Although not all of these studies demonstrate a significant improvement in symptoms with delta-9-THC or CBD, evidence is accumulating that cannabinoid drugs may be useful in at least a subset of patients, and at least as an adjuvant therapy.  Even where cannabinoids have failed to reduce spasticity according to the Ashworth scale, it has been pointed out that many commonly used anti-spasticity drugs have also failed to generate statistically significant results according to this scale. 


Long-term studies suggest that cannabinoids are reasonably well tolerated by patients but there is still concern about potential long-term adverse effects, such as cognitive impairment, impaired foetal development and psychiatric side effects.  However, it must be recognised that many conventional anti-spasticity drugs such as Baclofen also have significant side effects.  It should also be noted that in some countries cannabis is an illegal drug, which affects its accessibility.   



Your questions answered


Q :   My spasticity comes and goes and is often triggered by heat – I’ve tried ice but is there anything else I can do to help prevent it coming on?


A.  The first thing to do in order to prevent heat from worsening an MS symptom is to avoid it whenever possible.  Moderately warm showers rather than hot ones are recommended.  Many people with MS also avoid sunbathing and performing some activities in the heat (such as exercising under the hot midday sun).  Other ways to help curb the heat’s influence on worsening symptoms is to use air conditioning, drink cold beverages and wear light, loose-fitting clothing.  Some people with MS use a body cooling system to avoid becoming overheated.  While these systems are available in different countries, they can be very expensive and have not been tested in rigorous studies with large numbers of subjects. 



Q.  My legs are often sore and stiff at night and stop me from sleeping.  Why are the symptoms worse at night and are there any exercises I can do before bed to help?



A.  You may be describing restless leg syndrome (RLS), a condition in which your legs feel extremely uncomfortable while at rest.  RLS has been found to be a very common problem for people with MS, although the cause is unclear.  An evaluation at a centre that specialises in sleep disorders would help to better understand your symptoms.  The feeling is usually relieved by moving around and this is why it seems like the symptoms worsen at night.  Some strategies for managing RLS include reducing caffeine and alcohol intake and regular, moderate exercise.  A healthcare provider can recommend appropriate exercises and/or medications. 



Q.  I have a pressure sore on my tailbone.  My MS nurse mentioned that this can worsen my spasticity.  What are other types of stimuli can aggravate spasticity?


A.  Cutaneous stimuli (those that relate to the skin) that can aggravate spasticity include ingrown toenails, broken or infected skin and tight-fitting clothing.  Visceral stimuli (those that relate to internal organs) that can worsen spasticity include bowel dysfunction, bladder infection and urinary retention.   Silvia Traversa, from the Italian MS Society, spoke with Giulio Adamo about how he deals with spasticity.  Giulio is 61 years old and retired and lives with his wife in Genoa.   







Compliments of:


Multiple Sclerosis International

Federation (MSIF)


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