Transcript Muscle stiffness and spasm (2)

Muscle stiffness and spasm in
MS
Miranda Olding RGN MSCN
November 2012
The nervous system
Made of nerve cells(neurons)
and ‘glial cells’(meaning ‘glue’)
Neuron.
Information passes as an
electrical current down the axon,
And then electrically, or chemically,
as a ‘neuro-tranmitter’, in between
Neurons.
Neurones
http://www.bbc.co.uk/schools/gcsebitesize/science/aqa/nervesandhor
mones/thenervoussystemrev2.shtml
http://www.childrenshospital.org/research/_neuron/index.html
Neurotransmitters can be either excitatory
(stimulating),or inhibitory, (calming); the amount of
excitatory or inhibitory input the cell receives dictates
whether the cell fires or the impulse is suppressed.
Biology of muscle spasm & stiffness
• The ability to switch off & calm down is as
important as the ability to switch on and rev up
• Excitatory signals fire other neurones into action;
inhibitory signals stop them firing. The ‘firing’ is
Action Potential – an electrical transfer of energy.
• Spasticity occurs as a result of an imbalance
between the excitatory and inhibitory signals
from the brain and/or spinal cord.
• The nerve pathway connecting the brain and
spinal cord is made of upper motor neurones.
• The pathway between the spinal cord and
muscles is made of lower motor neurones.
• In MS, ‘spasticity’ ( muscle spasm & stiffness) is
thought to be due to nerve conduction being
affected by lesions located in the brain or spinal
cord.
• This means that the upper motor neurones
struggle to regulate messages to the lower motor
neurones.
• The lower motor neurones can then become
overactive and hypersensitive, causing stiffness or
spasms in the muscles.
Some of you may be familiar with
this feeling….
…but you probably don’t make this much fuss
Interventions for muscle stiffness
and spasm
Physiotherapy,
Exercise
Stretching
Managing MS,
Prevention &
Trigger factors
Oral
Medications,
Food factors
& herbs
Patient
Intrathecal
Baclofen
(ITB™)
Therapy
Neurosurgery,
Orthopaedic
surgery
Injection
Therapy
Trigger factors
• Check you don’t have a urine infection –
get your urine dipsticked, and get
treatment if leucocytes/nitrites present
• Check you don’t have any infection, sore skin,
ingrown toenails, clothing/splint/shoes that are
chafing, or constipation – treat immediately if so
• Posture; how are you sitting, moving & sleeping?
– all these things can trigger worse
spasm/stiffness.
• Interferon therapy, esp high dose
• Periods of increased stress
Physiotherapy
Assessment
• Inhibitory mobilisation techniques
• Normal patterns of movement
• Active and passive movements
• Positioning / posture
(sitting, wheelchair, lying, standing)
• Splinting and orthotics
• Proprioceptive neurological
• facilitation techniques (PNF)
• Bobath technique - uses intensive handling to inhibit
abnormal tone and movement patterns
• Stretching
• Functional Electrical stimulation
• Standing
Your Physio can also teach you
self-management techniques like:
•
•
•
•
Home exercises/stretches
Exercise classes
Appropriate strengthening
Use of:
–
–
–
–
–
Free weights
Machines
Theraband
Swiss balls
Aquacise classes
Active movement exercise
• Recent research showed this to be the most
effective form of exercise for spasm / stiffness.
Stretching & range of movement
Helps to keep range of movement & flexibility
Can be done with a practitioner, eg physio, shiatsu,
In a class, like yoga
Or as a home routine, by oneself or with another person helping.
Muscle relaxant medication – all (except
dantrolene) affect neurotransmitters, promoting
increase of inhibitory transmitters like GABA
Drug
Dose
Action
Common side effects
Baclofen
5-40mg x 3 daily
GABA – B (brain)
Sedation, weakness
Tizanidine
2-12mg x 3 daily
A adrenergic agonist
(brain)
Sedation, dry mouth,
low blood pressure
Liver toxicity
Diazepam & other
benzodiazepines
Depends on drug
GABA-A (brain)
Sedation, can cause
dependency quickly
Dantrolene
25-100mg x 4 a day
Ca 2 release
(muscles)
Sedation, digestive
upset, liver failure
Gabapentin
100-1200mg x 3 a day Vk ch ? GABA (brain)
Weight gain,
sedation, poor
concentration,
unsteadiness
Pregabalin
Same mode of action
as Gabapentin, but
lower dose
Both drugs are “ off
label”
Same, second-line
treatment, more
expensive, and
Muscle relaxant basics:
‘start low and go slow’
• If you need to start or increase baclofen muscle relaxant
medication, get a tablet cutter, and increase in half tablets,
every 3 days, until you find the right dose, a to a max of 90mg
a day, in 3 split doses; ask your GP to adjust your prescription.
• See your MS nurse or neurologist again if this doesn’t work –
you can go higher with supervision & there are other options.
• If baclofen causes undue drowsiness or weakness, tizanidine
may be tried; you’d need a blood test before & for the 1st 3
months to check your liver can process it.
• Initial side-effects may wear off after a couple of weeks
• Combinations of drugs may be used if trying them alone has
not, or if top dose is reached without desired effect.
Alt
Alternatives?
LDN
• Many people with MS report improvements in
spasm with LDN; it’s not licensed for MS.
• This means your GP could prescribe it if they
want to, but may have to get private & pay
• Licensed drug 50-150mg, for heroin addiction
• 1.5 - 4.5mg for MS, 3mg top dose for spasms.
• Not be used with Beta-interferons or opioids
• An opioid antagonist, stimulates production
of body’s own ‘feel good’ neurotransmitters
Research & Testimonials
• Research is preliminary, not large scale, lack of
incentive as drug is already out and cheap
• Use is driven by testimonials and campaigning
websites, eg www.LDNResearchTrust.org
• Testimonials and preliminary research report
reduction in MS symptoms, most commonly in
• Spasms & fatigue
• Also many reports of cessation of relapses
• Stopping of progression
How LDN works
• LDN is an opioid antagonist – it blocks the uptake of
the body’s own natural endorphins, briefly, at night,
and thus stimulates the production of more.
• The interaction of naltrexone with microglial cells
results in a reduction of proinflammatory cytokines
as well as neurotoxic superoxides, which may be how
it affects the immune system (reducing relapses)
• A good essay on LDN is available at
http://www.ldnresearchtrust.org/uploadeddocumen
ts/dr-zagon.pdf
Drug free strategies to boost
inhibitory neurotransmitters
• Terry Wahls in her book suggests:
• Magnesium supplement 500-800mg daily.
Also in: pumpkin seeds, spinach, black beans,
chard, pinto beans
• Organic sulphur – needed to generate GABA.
Good sources: onion & cruciferous veg/greens
• N-acetylcysteine (NAC) helps generate GABA.
2g a day. Supplement. In: red pepper, garlic,
onions, cruciferous veg, oats, wheatgerm.
Drug free
• Almost all functions of the brain require adequate amounts
of the vitamin B family – many practitioners recommend
supplementation as well as consuming healthy foods
containing vitamin B
• www.theworld’shealthiestfoods.org is a great site for
finding out where to get different nutrients from foods
IMPORTANT: It’s important that you take responsibility for
any supplement or herbal medicine that you take, and check
that the product and dose is safe for you to take with any
existing conditions, medications, or other supplements.
Meditation
Also has a calming effect on neurotransmitters
in the brain, and reduces the effects of stress
References re meditation from
PubMed
•
Serum hormonal concentrations following transcendental meditation--potential
role of gamma aminobutyric acid. Elias AN, Wilson AF. Med Hypotheses. 1995
Apr;44(4):287-91.
•
The effects of mind-body training on stress reduction, positive affect, and plasma
catecholamines.Jung YH, Kang DH, Jang JH, Park HY, Byun MS, Kwon SJ, Jang GE,
Lee US, An SC, Kwon JS. Neurosci Lett. 2010 Jul 26;479(2):138-42. Epub 2010 May
28. Clinical Cognitive Neuroscience Center, Neuroscience Institute, SNU-MRC,
Seoul, Republic of Korea
•
Yoga Asana sessions increase brain GABA levels: a pilot study.Streeter CC, Jensen
JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DB, Ciraulo DA, Renshaw PF. J Altern
Complement Med. 2007 May;13(4):419-26. Division of Psychiatry, Boston
University School of Medicine, Boston, MA 02118, USA. [email protected]
Injectable therapies
• Anaesthetic / Diagnostic Nerve Blocks
– Procaine
– Lignocaine
• Neurolytic Nerve Blocks
– Ethanol
– Phenol
• Botulinum Toxin
• Intrathecal Baclofen
• Intrathecal Phenol
Injections
Advantages
•
•
•
Not permanent
Evidence to support efficacy in reducing spasticity and improving function
Effects are localized - not systemic
Disadvantages
•
•
•
•
•
Not permanent - may need to repeat injections
Ethanol and Phenol: require greater skill to inject, increased risk of
paresthesias, dysesthesias
Botulinum toxin: more expensive than other injections, may develop
antibodies
Only of use in single muscle spasticity
Not appropriate if contracture already present
Botulinum toxin therapy
• Naturally occurring substance
produced by bacterium
clostridium botulinum
• Powerful neurotoxin (type A)
• Blocks release of acetylcholine
at neuromuscular junction
• Results in muscle weakness
- effect in 4-7 days
- peak 4-6 weeks
- lasts 3-4 months
Botulinum toxin
Side effects
• Excessive localised muscle weakness
• Flu like symptoms
• Fatigue without objective weakness
• Dry mouth
Follow up
• Must be multi disciplinary
• Education
• Physiotherapy e.g stretching regime
• Splinting / casting
• Review goals 4-6 weeks post injection
• Medical review 3-4 months
Cannabinoids
• Research is mixed, most recent trial, clinical
measures of muscle stiffness did not change
• In a 2009 systematic review of RCT trials on
people with MS taking cannabis extracts (THC
& CBD) found that 5 out of 6 reported:
• a decrease in spasticity & improved mobility
• All reported side effects, related to dosage.
• Generally the treatment was well-tolerated.
• Study on whether cannabis protects against
progression found it did not. (Cupid)
Cannabinoids
• The cannabinoid medicine Sativex has been
licensed and seems to help about 30% of the
30% of people with MS spasms who can
tolerate it. As it is so expensive, many PCTs will
not fund it.
Cannabis is an illegal drug in the UK, however
a study in the Lancet reported lower rates of
harm to health than tobacco or alcohol
Known side-effects of Cannabis
•
•
•
•
•
•
•
Psychoactive, mildly euphoric ‘high’
Slight changes in psychomotor and cognitive function
Appetite stimulation
Increase in heart rate and decrease in blood pressure
Dry mouth and dizziness
May induce feelings of panic, anxiety and paranoia
Frequent, heavy users may develop an amotivational
syndrome
-Baker, Pryce, Givanni & Thompson Neurology (2003)
]
Types of cannabis
•
•
•
•
There are 3 main types of cannabis
Sativa , Indica and Ruderalis
Sativa is more commonly used for a ‘high’
For body relaxation and muscle spasm,
consensus seems to be to use Indica.
• It can be smoked in a joint or pipe, a water
pipe, or inhaled in a vaporiser, or sprayed as
tincture
• Made into a tea with oil, or a butter
Logistics of using cannabis
• There are many online sites discussing the
medical use of marajiauna/cannabis, eg here,
making a tincture like Sativex:
• http://patients4medicalmarijuana.wordpress.com/medical-use-ofcannabisvideo/marijuana-tincture
• Excellent article in MS magazine ‘New
Pathways’ by a person with MS who uses her
home grown cannabis for spasm at
http://www.msrc.co.uk/downloads/npwm_20
10_0060.pdf
Intrathecal Baclofen (ITB™)
Intrathecal Baclofen
• Surgically implanted pump ( under the skin)
delivers tiny doses of baclofen via
intrathecal ( into spinal space) catheter
• ITB™ /“Lioresal Intrathecal” administered by
programmable infusion system
• Effect 5x greater in legs than in arms
• Average dose 300-800 micrograms per day
compared to 30-120 miligrams oral
baclofen
Why Intrathecal vs Oral?
• Intrathecal
– Lower doses than those required with oral
administration
– Potentially fewer systemic side effects
• Oral
– Low blood/brain barrier penetration, with high
systemic absorption and low CNS absorption
– Lack of preferential spinal cord distribution
– Adverse effects, such as drowsiness, for some patients
Surgical procedures
• Invasive. Involves cutting of tendons in bad contractures
– Shouldn’t be necessary if appropriate physical and
pharmacological management started early
• Intrathecal pharmacological management requires surgical
procedure
• Neuro-surgery and orthopedic surgery can be considered
• Advantages
– Effects usually last a few years
• Disadvantages
– Anesthesia risks
– Non-weight bearing after bony procedures
– Risk of weakness, decreased function
Much about MS remains unknown &
new theories often emerge… eg
• Will the real multiple sclerosis please stand up?
• Peter K. Stys, Gerald W. Zamponi, Jan van Minnen &
Jeroen J. G. Geur
• ‘...questions have been raised as to whether
inflammation and/or autoimmunity are really at the
root of the disease, and it has been proposed that MS
might in fact be a degenerative disorder. We argue that
MS may be an 'immunological convolution' between an
underlying primary degenerative disorder and the
host's aberrant immune response. ..’
• Is multiple sclerosis a mitochondrial disease?
Peizhong Maoa and P. Hemachandra Reddya,b
Inflammation and degeneration
.
adapted from Compston A, Coles A. Lancet. 2002;359:1221-1231
Exciting possibilities
APS therapy
• Based on the function of the cell
• Electrically simulates Action Potential
• Dr. Lia Van der Plaat in Hull recently having
very positive results with people with MS with
pain – but marked improvements in muscle
spasm and fatigue also occurred.
• Clinical research project about to start in Hull
• MS Therapy Centre in Bedford investing in
machines to pilot therapy clinically
APS therapy logistics
• Personal machines cost around £1,200
• To be effective, need 3 x treatments of ½ hour
a week, ongoing.
• In Hull, clinic delivered a 6 week course
• Then helped people to access funding via the
personal health budget scheme
• We intended to duplicate this model – but
PHBs not working in our area currently, so will
try to help people to access charitable grants.
www.apstherapy.co.nz has good information.
Headquarters is www.apstherapy.com
Do everything to stay well now!
My favourite info resources for staying well with MS
www.overcomingms.org
www.TerryWahls.com
Stay informed!
• www.mssociety.org.uk/ms-resources/musclespasms-and-stiffness-ms-essentials-19
• www.mirandasmsblog.wordpress.com