Spasticity

[Sidesteps]

Hi everyone!  I have a rather simple question and think I'm seeking validity more than anything. I *think* I've had some trouble with spasticity but I always can attribute it to a possible injury (at least I think I can) despite not knowing what the injury is. These are the indicidences I can report:

1) In January 2010 - While on vacation in Hawaii, I woke with my right leg/knee really bothering me. I couldn't bend it without a lot of pain and it took MONTHS for it to get better.  I thought I must've stepped oddly but thought it was strange it was my knee and not my ankle without a noticeable injury. I saw an ortho who couldn't find anything wrong except range of motion issues as there was nothing on my MRI that showed up. I was referred out to a Physical Therapist and they treated my pain, loss of range of motion and weakness with stretching and strength moves. I had some trouble but it suddenly got better and I've not had problems since.

2) In June 2011 - I had a sudden pain, in my right rotator cuff shoulder and the tightness extended ALL the way down my arm. I had started working out a couple months before so I thought may that was it. I could not lift my arm above my shoulder and if I stretch I could feel the burning, tightness and pain into my tricep and forearm areas. It was really odd. I had a referral to a Rheumy who treated it with a cortisone shot. It was better within a couple weeks and I've, again, not had problems since.

3) Two weeks ago - I had my lumbar puncture. I ended up with the spinal headache and they went back in to do the blood patch. He had to move around quite a bit to get in the right spot for the blood patch. I was very sore for 24 hours and then was feeling better then I woke about 5 days ago, with a lot of discomfort in my bottom (tailbone area) and hips. This discomfort is a tightness mostly on my right hip flexor area that also extends into my hamstring toward my knee. It is both hips. I'm having trouble walking without pain. I have attempted to stretch but it's pretty painful, only seems to termporarily relieve the issue and only minimally.

I do not feel like I'm in a flare yet but I am sleeping more (9 hours or more a night) and I have that weird pressure I get in my right waist again. I have had an increase in my twitching/jerking since the lumbar puncture.

My questions:

Does this sound like spasticity? I think I'm more suspicious since this is the 3rd episode. This is also seems to connect with my waist "hug" and a direct result of the LP. It doesn't seem to quite make sense that I'd have hip flexor spasticity from a puncture that isn't really affecting my lower back muscles.

I see the MSologist on Wednesday. Is this all worth mentioning? Any additional thoughts?

[Sidesteps]

Oh gosh I did not even think of hypersensitivity.

Well - I am confident this is spasticity. I have had numerious people tell me in my life span that I am unusually flexible. I had taken flexibility tests off and on and have never had issues with stretching...until this last year and half.

This morning in the shower I went to shave my legs (lol, sorry, tmi) and could not bring my right leg straight. The right hamstring and glute are so tight my leg doesn't want to straighten out.

Good timing to get my test results and see my Neuro. Hopefully she can give some insight.

[jensequitur]

Hey, sorry - this topic is really complicated, and I still don't understand it all!  What have you tried so far for your muscle knots?  Does a muscle relaxer help?  Sometimes a nerve injury can cause the problem you're talking about.  Many MS problems are similar to spinal injury problems.

To my way of thinking, they could give you an oral muscle relaxer and see if that helps.  If the knots are caused by a bad back, that should cause them to relax - for at least a second or two.

Sidesteps - I think that spasticity can be like a muscle knot, but I'm not sure if they would feel 'bruised.'  It sounds more like you have an extra-sensitive spot.  That sometimes happens with nerve damage.  Patches of skin can be really sensitive to the touch.

[Sidesteps]

Chefaid,

I am not sure.

I know that when I was going through a lot of issues last year that my neck and upper back were extremely tight... I was in a lot of pain. I finally received 6 weeks of massage therapy and that helped. It was pretty intense therapy though 2 hours the first week and 45 minute sessions each week that focused only from my neck to my glutes to release all the tightness.

I think it really is hard to determine spasticity without seeing a pattern. I always seem to attribute it to an injury because it feels a lot like one at first....then the pattern starts to emerge and you notice little differences.

[chefaid90]

i am still lost. can anyone look at my question and see if than of what was said fits me? i just cant grasp what is being said. sorry

[Sidesteps]

Okay, so if I'm understanding then my issue could be sensory as I have muscle weakness in my right leg/foot that was picked up in the examination. Since I appear to be having some increased issues in that leg, along with increased muscle tension, then this is probably spasticity issues. I have a similar issue in my right hand but the tension has been interrmittent. How interesting!!!  I think this is starting to make sense.

Can spasticity also be like a muscle knot? I have a few "spots" on my leg that hurt like they are bruised but there isn't anything there and it's the same spot frequently. I don't notice it unless I touch it.

[jensequitur]

Let me see if I understand what Bob is saying...

So you've got three kinds of neurons in your muscles - sensory, motor, and interneuron (whatever those are!)  Motor neurons are in the gray matter, while sensory neurons are in the white.  So the white matter's more likely to be affected by MS than the gray.

If you're a patient with spinal cord injury, the muscles will contract when there is no motor neuron connection.  If you're a person with MS, you've lost some sensory neurons, so your brain is working to find where the muscle is by causing it to go into spasm.

As I said to Bob, I wonder if I have both.  I have the worst kind of sore/stiff/painfully tight sensation around my right elbow, and it's hard to use that arm when it's really sore.  That doesn't sound like a spasm caused by the brain to find out where that joint is.

[jensequitur]

Thanks so much!  You've helped me understand spasticity better.  I had thought it was a function of nerve connection only - I hadn't even considered the different kind of nerves running to that muscle.

I know I have some leg and hand weakness, but now the question in my mind is whether the spasticity is caused by motor neurons being severed (descending inhabitation, right?) or whether it's from sensory problems.  I'm thinking sensory - I don't have that drastic contraction of my muscles, and I can still walk.

[Sidesteps]

Can you guys put all that in lay mans terms? :) ;)

I completely understand that sometimes when you have injuries, you over-compensate and strain the muscles that were not being used this way.

In this case, there is nothing compensating. I had irritation, typical nerve irritation, from the lumbar puncture/blood patch. Other than I nearly went into shock and passed out, I didn't have any real difficulties. My lumbar was just very sore the next day and then improved slowly.

I woke 5 days later with a different issue. It's bad enough that it is affecting my walking style. It's definitely worse after periods of rest so it's not really an injury. It's muscle tightness and pain associated with trying to use the muscles in a way it doesn't want to go. This is primarily my right side which strangely is the only side I'm seeing this with; right side knee/leg, right side hip, right side shoulder/arm, right side waist pressure/tension.

The only thing that stands out different is my left foot cramping and deformity that last about day when I was getting ready for a garage sale.

I have my follow up tomorrow for my test results. I guess, either the light bulb will present itselfand this may answer itself with a positive result but, either way, I will need to bring it up to her tomorrow.

[chefaid90]

could this be the reason why my back muscles wont release? I have certain spots on my back that they muscles wont relax, they have tried everything to get them to relax but nothing works. I am not dx with anything yet still trying to get to see a neuro pcp just ordered emg/ncv. There was no injury or anything to my back it started slowly and is progressing and no one knows why.

[COBOB]

Yes, spasticity can be caused by loss of "descending inhabition" in which case the muscle will naturally contract.  This is common in contracture seen in spinal cord injury patients.  This is caused by prolonged excessive muscle tone.

In the case of some MS patients, as the same Wikipedia article states: "Strangely, however, rather than being in the motor nerves as might be assumed to be the case, spasticity actually stems from the sensory nerves."  In engineering, this is a feedback loop. Muscles pull, brain knows and limits pull.  Failure of the somatosensory side of the loop can lead to excessive pull.  

Considering that most of the descending motor tracts are grey matter (eg: grey matter horns of the spinal cord remain uneffected), and the the ascending white matter tracts are typically effected by demyelination (paresthesias, etc.) I can understand where my neurologist is coming from when he explains that the muscles move, under my control (motor cortex,) but sometimes, the body doesn't know where the muscles are (laying down, sleeping, etc.) and they fail to report their position and movement to the white matter somatosensory cortex, so the brain triggers the muscles (motor cortex).

I have a passing knowledge of neuro anatomy and physiology.  I can listen to what the doc says and it seems to make sense,  Obviously, my muscles must be providing some level of feedback to my brain since I do not have any contracture.  It also seems that standing and moving around can calm my spasticity at night.  Obviously both mechanism can be at play, but my gut says that the somatosensory has a bigger effect in my MS, since I have had no paralysis or voluntary motor issues and tons of sensory issues.

Bob

[jensequitur]

Hmmm... that still doesn't sound right - like I said, the muscle will spasm if there's no connection to the brain.  If the brain isn't talking to the muscle, then it can't tell the muscle to spasm.  Off to the health page!

... and the health page doesn't have the information... off to Wikipedia!

Ah, here we go:

http://en.wikipedia.org/wiki/Spasticity

The important bit: "Precise cause aside, whenever there is a loss of muscle tone inhibition from the brain to the spinal cord such that muscles become overactive, this loss of inhibitory control can cause an ongoing level of contraction, with decreased ability for the affected individual to volitionally control the muscle contraction, and increased resistance felt on passive stretch."

[COBOB]

Gabapentin is not a pain receptor drug.  GABA drugs are anti seizure medications that increase the ion channel thresholds.  They do nothing for nociceptive pain, just neuropathic pain (paresthesias).  

The neurologist explained that the brain must receive joint position messages and muscle strain messages, of the brain fails to recognize the bodies position in relation to itself (the basic definition of proprioperception.)
When this happens, the brain attempts to "find" the position my stimulating muscles by increasing tone.  There is no peripheral nerve damage, but CNS somatosensory issues.  The increase in tone is an attempt by the brain to "test the feedback loop" and learn the positions.  As that fails, the brain continues to increase the tone of the muscles.

Bob

[Sidesteps]

I've had my foot distort with cramping. It twisted my toes and I could barely walk. This severity lasted nearly 3 - 4 hours but I still had milder cramping and tension for a couple days following. This WAS during a "flare" in June. It eventually resolved. (I probably should have put that above - I did talk to the doctor about this since she specifically asked about cramping when she picked up on my weak right foot.)

My hip, glutes and hamstring only cramp up after I've been resting and try to do anything too quickly. I think I'll talk to the doctor since it does seem to relate to the punctures though I'm not sure how. Odd.

[jensequitur]

I think the real problem with spasticity is that muscles lose connection with the brain because of damaged nerves.  The brain is always telling our muscles to relax, and with that loss of connection, the muscle starts spasming.  

With a slightly damaged nerve, the muscle has 'increased muscle tone.'  That's spasticity.  With more damage, the muscle starts to spasm, and that's when you get the toe that stands straight up and won't relax, or the hand that spasms unexpectedly.  Spasms and spasticity are pretty common with MS.

However, I've never heard that the muscle tone created through nerve damage is to create proprioperception signals through an attempt by the brain to locate those muscles - after all, the brain isn't talking to the muscles, because of the damaged nerves.

That being said, Gabapentin will not help with spasticity - it's a pain receptor drug.

[COBOB]

Gabapentin (and the other anti-seizure medications) may not help with spasticity.  The "pain" from spasticity is real "nociceptive" pain (pulled muscle - abnormal muscle tone.)   Gabapentin (and the other anti-seizure medications) are used to treat "neuropathic" or somatosensory pain.

Spasticity is caused by a failure in the somatosensory and/or proprioceptive systems not letting the brain know where the body parts are at a particular time.  The brain's response if to contract muscles and increase the muscle tone to "locate the position" of the body parts.  

Drugs like Zanaflex and Baclofen are antispasmodics and reduce the muscle tone.  The muscle pain can be treated with anti-inflammatories and analgesics (including narcotics when needed.)

Bob

[kiddo2860]

I have had similar experiences with my knee/leg sudden onset, weeks to go away, then the same problems that bairdy is experiencing.  I had a back bout for about 6 weeks during the hot season (June/July/Aug) then it eased up.  Since I have DDD in my lumbar region, SI Joints the professionals put most of this down to muscle/arthritis problems.  Yesterday it all came back including the MS Hug? this morning.  Have not been diagnosed officially yet and one muscle neuro disagrees with the MRI report and my doctor.  See another neuro next week.  I said in another post that I am taking all my posts as well as my binder of reports, etc to the neuro.  Very frustrating.

I would mention all of it.  Keep us posted.

Pat

[bairdy]

hi
i can relate to the pain in your hips that effect your thigh i have just got over six weeks of this that came out of nowhere !!  it affected my right side above waist line too with pressure ?? hug ??
i could not walk more than ten yards without being in very bad pain .

i had to use my wheelchair for any distance walking i upt my gabapentin and baclofen to ease it . i thought it could have been ahrthritis coming on but it went after six weeks.

i also had an lp in march that effected me in a similar way to you so sore with spasms and stiff hips.
mt neuro pt said its spasticity causeing my problems
hope this helps sorry i cant give tou any more advise just that you are not alone
regards bairdy