Why Are MS Spasticity Symptoms Worse At Night?

The main feature of spasticity is stiffness or increased resistance when attempting to move a limb or joint. 

Other features that may be associated with it include spasms, pain, weakness and clonus (involuntary contractions in a rhythmic pattern in response to sudden stretch of a muscle). It can vary in intensity from person-to-person. 

Spasticity can be triggered at any time through a variety of stimuli: 

• Bladder problems 
• Bowel problems 
• Skin problems e.g. Irritation or pressure areas  
• Infections 
• Pain and discomfort  
• Excessive fatigue  
• Extremes of temperature  
• Stress and anxiety

Spasticity can feel worse at night as:

• Spasticity can be aggravated by reduced movement, such as when you’re lying in bed
• Tight muscles may make it difficult to relax when trying to sleep
• Pain from symptoms can prevent sleep 
• When experiencing clonus (involuntary contractions), limb movements may prevent you falling asleep 

Spasticity may also feel worse in the morning due to the time you have spent inactive in bed.

Tips to help MS spasticity at night

Pain and insomnia are linked in people with MS due to muscle tightness. Experiencing insomnia can increase fatigue, which can create stress and increase spasticity. Managing these symptoms is essential to improve your quality of life.

There are plenty of things you can do to improve spasticity. 

1. Managing MS Spasticity triggers

Managing factors that trigger your spasticity can help ease the symptoms and spasms. Being able to identify these triggers is important in managing your symptoms. 

• A review of your bladder, bowel and skin care management techniques could improve the situation. Advice and assistance can be given by your GP, a nurse specialist or Continence Advisor.
• Pain and infection should be treated directly
• A good position when lying, sitting or standing will help you manage your spasms, spasticity and prevent discomfort. 
• Loosening tight garments may help to relieve spasticity.

 Positioning

• Make sure you are in a comfortable sleeping position – look at your mattress; is it comfortable, how long have you had it for and do you need to replace it?
• For those that sleep on their sides, ensuring that your pillow isn’t too high or too soft is very important, as this can put more strain on your neck and spine, often worsening muscle tightness and spasticity

2. Spasticity Medication

You may be offered medication to relax muscles or to aid sleep if spasticity is worse at night, think about the timing of your medication to make sure you get the best effect when you need it most.

Medication can come in the form of: 

• Tablets which work on the entire body  e.g. Baclofen, Tizanidine, Clonazepam  
• Baclofen (Lyflex). Baclofen is the most commonly prescribed medication to treat spasticity and spasms in MS. It is important to increase the dose slowly to get a balance between minimising spasticity but not making muscles weak.  Baclofen should not be stopped suddenly as it can have lead to severe withdrawal symptoms.
• Benzodiazepines. These muscle relaxants work through sedation, reduced anxiety and muscle relaxation. The  sedative effect may reduce spasticity at night, permitting uninterrupted sleep. However, these drugs also produce tolerance and dependence, limiting their long-term use.
• Injections which target the medication to a specific muscle or group of muscles e.g. Botulinum Toxin, Peripheral Nerve Block 
• Botox injections which temporarily help severe spasticity in a targeted area
• An implantable device e.g. Baclofen Pump, this is generally used when symptoms are severe and oral medication is not effective. This medication is delivered at the spinal cord level. This allows you to vary drug doses depending on your activities, allowing more flexibility in self-care throughout the day, and it helps more effectively control night-time spasms
• Sativex / Cannabinoids. Nabiximols (Sativex) is a cannabis based spray and can be used in addition to any current anti-spasticity medication. Its an equal mix of tetrahydrocannabinol (THC) and cannabidiol (CBD), and can help with spasticity symptoms. 

3. Stress relief

Feeling negative or depressed has been reported to increase spasticity. Using stress reduction techniques could help with spasticity symptoms. Try meditation, relaxation techniques, deep breathing, and guided imagery. 

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4. Temperature

Some people find that cold and hot temperatures can make spasticity worse. This could also be a result of Uhthoff’s phenomenon (the worsening of multiple sclerosis symptoms that some people experience when exposed to heat).

Make sure you maintain a comfortable temperature at night using air conditioning, a fan, bedding or heating when necessary. 

Other ways to avoid spasticity symptoms related to temperature: 

• Use cooling devices or ice packs after exercise to reduce spasticity.
• Avoid temperature extremes. 
• Cold temperature may be helpful for those experiencing muscular contraction (clonus). Try using hand held fans while out or bigger fans for the bedroom while trying to sleep. 

5. Stretching and movement

It is important to maintain flexibility with specific stretches, as spasticity can be aggravated by reduced movement. A physiotherapist will be able to help you with a program of suitable stretches.

Studies have reported positive effects of exercise on reducing spasticity in persons with MS. These have included cycling [Sosoff et al. 2009], a group exercise intervention [Tarakci et al. 2013] and locomotor training [Giesser et al. 2007].

MS spasticity exercises

Spasticity can cause muscles to shorten and joints to stiffen which can then increase muscle overactivity. Exercises to increase flexibility and increase muscle tone may be useful. Prolonged stretching can make muscles longer, helping to decrease spasticity and prevent contracture.

Aim to stretch daily to muscle’s full length. It is also important to do some ‘range of motion’ exercises, used to keep joints strong and flexible. Make sure you balance your movements – do the same number of reps on each side and combine ‘push’ and ‘pull’ exercises. 

Here are our top tips:

• Do the correct type of exercise for you – strenuous or fast activities may increase tone and spasticity.
• Always stretch before and after exercise
• A physiotherapist may be able to help you with a full programme of stretches tailored to you 
• Your local MS centre might be able to help with classes or physiotherapy for people with MS 
• Try to exercise in a cool environment

A thorough stretching program will include exercises in certain sitting or lying positions that allow gravity to aid in stretching specific muscles.

Exercise ideas:

• Massage the calves, Achilles tendon area and outside of thighs. 
• Next, flex the feet as far as you can and hold, then point your toes to stretch in the opposite direction. Repeat for each leg. 
• Rotate the ankles first outwards, then inwards and repeat on the other leg
• Bend and extend the legs several times and then hold the extended pose for a short while (1 min). Repeat.

If you are having spasticity symptoms at night, try some moves in bed e.g. drawing knees up to the chest and letting one knee fall to the side, then repeat on the other side. Otherwise, get up and try some moves slowly and mindfully. 

Types of exercise you can try to improve spasticity symptoms:

Yoga / adaptive yoga 

Yoga is a flexible practise and there are lots of types which you can choose from to suit you – it is also something you can do at home.  You can use props such as a chair, bolster or the wall.

Yoga and pilates can also help improve posture and positioning. Yoga has also been found to decrease fatigue. Other studies have reported improvement in anxiety, depression, fatigue, bladder function, pain, spasticity, weakness and walking. 

Here is an example yoga relaxation sequence you can use. This can also help you to relax. 

Pilates / MS pilates 

Pilates stretching exercises can also be very helpful. Pilates is a series of exercises based on whole-body movement and are low impact, building strength and control. 

This can also help with other MS symptoms such as cognitive symptoms and like all exercise, it can reduce fatigue levels, as well as improve things like strength, mobility and bowel and bladder function. 

Passive range of motion exercise 

Passive exercise is when something or someone is moving your joints for you. 

• Motorized physical therapy exercise cycles – these allow you to get exercise regardless of endurance or strength levels 
• Active treadmill exercise – assisted by a training partner or training equipment such as elastic bands. 
• Locomotor training – where you are suspended in a harness over a treadmill  
• A passive stretch – where you assume a position and hold it with some other part of your body, or with the assistance of a partner or some other apparatus.
• Proprioceptive Neuromuscular Facilitation (PNF) – a more advanced form of flexibility training, which involves both the stretching and contracting of the muscle group being targeted. 

To improve spasms, try strengthening exercise to keep your muscles strong. This could be using light weights or exercise bands. This will depend on the intensity of spasms and the individual.

To help manage spasticity at night, a combination of factors can help reduce the symptoms. A combination of medication, improving sleep positioning and gentle exercise can help manage the symptoms effectively.