Weakness, fatigue, and spasticity overlap and are easily confused with one another. Fatigue is an overall exhaustion; spasticity has symptoms of overly tight muscles, overly flaccid muscles, and spasms; and weakness shows itself as a loss of strength and control in the extremities.
When caused by MS, weakness is a result of damaged nerve impulse flow, preventing instructions from reaching the extremities. This type of weakness does not result from any type of loss in muscle strength.
The most common symptom of weakness is one leg feeling heavy and being difficult to lift, especially at the end of the day. Those who have had MS for a long time could well have both legs affected. Such weakness may be particularly evident when stepping up onto a stair or curb. Although less common, some may experience similar sensations of heaviness or clumsiness in one or both of their arms and hands. Losing the ability to grip, push, or lift is often very frustrating.
Weakness, as with any MS symptom, may be temporary – disappearing as inflammation from an exacerbation decreases. Treatment for weakness in this type of situation may involve corticosteroids to reduce inflammation in an attempt to lessen the intensity and accelerate recovery from an exacerbation. Resting the affected muscles will conserve energy and also result in decreased weakness.
When weakness occurs for a year or more, a different approach must be taken. Strategies must be developed to avoid overuse of the affected limb. Using a cane will certainly remove some of the pressure on a weak limb, as will using a brace or other appliance. A weak wrist may be supported by a lightweight splint or a bowler's brace.
People who are moderately to severely weak are often reluctant to use a wheelchair. But using a wheelchair can be very helpful in conserving energy, and an individual may be able to do more as a result.
If desired, the use of assistive devices may be reserved just for times of extra activity. Using a cane will not make someone more dependent on others, but rather increases independence by giving the strength to continue with activities for a longer period of time.
Planning ahead is particularly valuable for dealing with weakness. When traveling or involved in a prolonged activity, arranging for a wheelchair in advance to cover long distances can save time and energy. Being aware of limitations while organizing one's schedule will avoid late-day weakness.
Some people with MS will attempt to overcome a weakness problem by trying to strengthen muscles with exercise and lifting weights. This often serves to further fatigue the muscles. On the other hand, lack of exercise can cause a muscle to become weaker from disuse.
Although this sounds like a "no-win" situation, a physical therapist can design a program aimed at keeping the affected muscles healthy while avoiding further weakness. One of the goals of physical therapy is to strengthen muscles that may be affected by MS and help support weak muscles.
Aerobic exercise or machines, such as those for cycling or rowing, may be recommended for some to strengthen without weakening. Water exercise, also known as hydrotherapy, offers the benefits of buoyancy.
By eliminating the pull of gravity, a person with weakness is able to have greater range of motion while exerting less energy to move the limb. The cooling effect of water on core body temperature may also lessen exercise-induced fatigue.
Before starting any type of exercise program, always consult a physical therapist. Exercise without the approval of a physical therapist or physician might be harmful and actually worsen someone's condition.
In general, working with a physical therapist is helpful for maintaining proper muscle tone without creating further weakness. Aside from treating an exacerbation with corticosteroids, no drugs are available specifically to improve weakness. Weakness can be worsened by other symptoms, and successfully treating those symptoms will help to decrease weakness. Chronic weakness caused by MS is best approached through physical therapy, rest, planning ahead, and assistive devices, such as a cane, brace, or wheelchair.
Often a certain neurological condition will produce a specific type of trembling or shaking – also known as "tremor." The location and number of cycles per second that an individual shakes is typically consistent, depending upon the type of ailment. With MS, however, tremor varies in terms of speed, severity, location, and duration. Tending to come and go, MS tremors may affect the limbs, trunk, head, or even one's voice and speech.
Tremors from MS may simply be annoying, or they can be extremely disabling. An affected area may experience tremor while at rest, or may shake only when a purposeful movement is made. Oscillations (back and forth motion) may be observed with gross tremor, while others may experience fine tremor, where shaking is barely perceptible. In such instances, minor adjustments to the posture, such as holding one's arm close to the body, may be enough to make the condition tolerable.
Inflammation or demyelination in the cerebellum or its connections with the brainstem is frequently the cause of tremor for people with MS. This area of the brain is involved with balance, controlling the coordination of movement and skeletal muscle activities. While this is the most common cause of MS tremor, it is unfortunately also the most difficult to treat.
This type of tremor normally appears with purposeful movements and is often a slow, gross tremor of the legs or arms. Similar to many MS symptoms, emotions, stress, and fatigue usually worsen tremor. Unlike many MS symptoms, this condition responds minimally to steroid treatment.
Tremor may also be present with "ataxia," a condition where someone experiences balance problems, often with sudden tipping or swaying; jerking or shaking may occur as well. These symptoms may result in a loss of coordination and an inability to perform simple tasks. This is not common for most people with MS, as most of those who do develop this type of tremor simply have a slight oscillation of the head or body.
Another type of tremor sometimes observed in people with MS is the physiologic, benign essential, or familial tremor. It usually is a trembling which vibrates at 8 to 12 cycles per second. A physiologic tremor is not related to MS inflammation or demyelination and is very treatable with medication.
Some people experience jaw, lip, or tongue tremor that may affect their ability to speak efficiently. Therapies to help this condition are discussed in a later section devoted to speech difficulties.
Tremor in MS patients may be approached from a number of directions. Treatments include physical therapy, assistive and adaptive equipment, drug therapy, and surgery.
Certain exercises may be taught by a physical therapist to increase stability. Exercises for the shoulders, body, pelvis, and hips are particularly helpful for tremor in these areas.
"Patterning" is frequently used by physical therapists to promote muscle control and development. This technique uses repeated movements to increase muscle coordination. As the patient repeats these guided movements, the physical therapist adds increasing amounts of resistance, helping the movements to become strengthened. Eventually, these movements become automatic, and tremor may be decreased.
Adding extra weight to a limb, especially at the ankles or wrists, promotes more control. This is believed to occur as more muscles are needed to lift extra weight and this helps to overpower the tremor. It also increases sensory information sent back to the brain. Occasionally, adding weight worsens cerebellar tremor.
Adding weights to household items may make them easier to control. These include pens and pencils, eating utensils, brushes, canes, and walkers. Other supplies and equipment around the house may also be adapted with easy-to-grip handles and nonskid surfaces to assist individuals with tremors.
When a tremor becomes significant enough to interfere with one's ability to perform, a person may choose to use a brace to immobilize the affected region. Special braces are available to go across a joint, preventing random movement and allowing for the wearer to regain control.
Arm and hand braces work well and may be used when performing a task, such as eating or writing. Braces for the foot and ankle enable the wearer to walk more steadily. Head and neck braces are available too.
Knowing tremor may be worsened by stress or anxiety, medications which have a calming effect are sometimes prescribed. Hydroxyzine (Atarax®, Vistaril®) is a tranquilizer and antihistamine that reduces a tremor by relaxing the individual and calming stress which may have provoked the tremor.
Clonazepam (Klonopin®) works similarly to hydroxyzine. Care must be taken by the physician, however, to prescribe a dose which is effective but not so strong as to sedate the patient excessively. This drug can cause tolerance and dependency.
Propranolol (Inderal®) is a beta blocker – an agent which blocks the nerve flow along certain nerves known as "beta fibers." It is typically given for high blood pressure or angina. Propranolol is usually effective in treating only physiologic tremors. Doses should be started low and gradually increased until an optimal level is reached.
Amantadine (Symmetrel®) helps to reduce shaking for some individuals. This medication also has antiviral properties and is sometimes prescribed for people with MS to alleviate fatigue.
Baclofen (Lioresal®) is a drug often taken by people with MS to treat spasticity. It also helps to slow tremor, but the dosage must be carefully watched as baclofen produces weakness as a side effect.
A drug normally used to fight tuberculosis, isoniazid (INH) with pyridoxine, is also helpful in controlling severe gross tremors which are posture related. Unfortunately, large doses of isoniazid are needed to be effective, and this can result in liver toxicity. Given the danger, this medication should only be used in extreme cases, and liver function must be evaluated regularly.
Other drugs that may be used to treat tremor include primidone (Mysoline®), and acetazolamide (Diamox®). Primidone is an anticonvulsant and acetazolamide is a diuretic (water pill). Both have properties which may reduce some tremors.
As with many other MS symptoms, surgery is only considered for tremor when the condition has been severe and chronic, with no other options for treatment. A thalamotomy may be performed to give relief from a chronic cerebellar tremor. This surgical process cuts or freezes the thalamus gland in order to destroy the part of the gland that produces tremor. A complication of thalamotomy is severe dysarthria, a condition where speech becomes difficult and poorly articulated.
For individuals with incapacitating tremor, thalamic stimulation may also be an option. This procedure uses surgically implanted electrodes to stimulate the thalamus – a portion of the brain that helps to control movement. Stimulation to this part of the brain may reduce or stop tremor.
Thalamic stimulation is safer than thalamotomy, but still carries risks, and the cost is very high. This procedure should only be considered for severely affected individuals.
A variety of MS symptoms may lead to a walking difficulty. Problems with vision, balance, strength, coordination, muscle tone, and sensation can each have an effect on how well a person is able to walk. As with so many MS symptoms, the first step toward a treatment is to determine the underlying cause(s) of the problem.
Spasticity can cause problems in gait and coordination. If this is the case, drug and other treatments for spasticity, which are listed in a previous section, may need to be used.
Following medical treatment, physical therapy is the next step in managing a walking difficulty. A physical therapist, neurologist, and/or rehabilitation physician (physiatrist) should be consulted for a thorough safety evaluation.
Physical therapy may help resolve walking problems when they are caused by a loss in strength and muscle tone. A physical therapist works to offset any physical imbalances that may interfere with an individual's movement. He or she needs to locate the muscles that are inhibiting movement and have become weak and/or inflexible. Strengthening and stretching therapies are then used to improve the muscles' functioning and bring them closer to the way that the less affected muscles perform. Proper bracing of weakened limbs is also helpful.
People will often attempt to create an exercise program on their own. Typically, the stronger muscles become overdeveloped, and the weak ones may be inadvertently ignored. This will create a further inequity between the strong and the weak muscles, causing balance, posture, and movement to worsen' and possibly encourage spastic reactions. The result will be an even greater difficulty with walking.
Posture is another crucial aspect of proper walking. As an individual's posture deteriorates, so does balance, coordination, and strength. By restoring correct posture, walking becomes more balanced and less awkward, alleviating strain to any one area of the body. The physical therapist spends much time teaching an individual how to stand, walk, and sit correctly.
Two commonly seen MS-related walking conditions are the foot drop and "hyperextension." Foot drop results from weakened foot and ankle muscles, causing the toe to drop while the person is walking. "Hyperextension" occurs when weakened hip muscles force the patient to swing his or her leg out to allow the foot to clear the ground. At the same time, the knee is pushed back further than it should, making it sore, swollen, and overextended.
In addition to physical therapy, the physical therapist may recommend an assistive device to help with walking and to avoid further damage. An ankle-foot orthosis (AFO) is a lightweight brace which cups the heel and keeps the foot from dropping. It slips into the wearer's shoe and under the pantleg, so no one can see it. A "cage" device or other types of braces are available for the knee in cases of hyperextension, to avoid any further damage.
Numerous types and styles of braces, appliances, canes, and crutches have been designed to assist people with walking difficulties. While offering greater support, these devices also add to stability and lessen the risk of falls and further injury to the affected areas.
A correctly selected and fitted walking aid will make walking more comfortable and easier for the individual. This will save energy and ultimately cause less fatigue. Proper selection and fitting is the key to success.
A specialist in physical medicine can be consulted to suggest the most appropriate types of orthoses. Some people purchase devices on their own which they believe will solve their problems. An ill-fitting or mismatched appliance can result in blisters, sores, worsened gait, additional fatigue, and a much greater risk of falls and injuries.
A physical therapist is vital to the success of not only choosing and fitting a device, but also proper usage. Many factors need to be taken into consideration, all of which require professional experience. For instance, canes are available in a variety of weights, shapes, and sizes. They are made of wood, aluminum, or a combination of materials. They may be adjustable, have different types of grips, have one or four legs, or a portion which goes along the forearm. Some people may even require two canes.
Once the therapist has worked with someone and identified the proper appliance, he or she will instruct the individual on how to use it properly. A cane is usually carried on the side opposite the weak leg. When going up stairs, the strong leg is used first. When coming down, the weak leg goes first. The cane goes alongside or before the weak leg on steps.
The expertise of a physical therapist is not limited to braces, appliances, canes, and crutches. Beyond these items, the therapist is skilled with fitting a multitude of walkers, wheelchairs, scooters, and other assistive devices. Choosing the correct size and type is absolutely crucial and will save much time and money.
Before recommending a certain model and size walker, wheelchair, or scooter, a physiatrist will take several measurements and consider many issues – including the type of use, environment, abilities, and special needs. He or she can select the correct chair and adjust the arms, seat, back, and leg-rest portions to the user. Custom padding, which also comes in many varieties, may then be added. Painstaking adjustments are made to place the proper type of padding in exactly the right places for a perfect distribution of weight.
To determine the cause, a medical professional should be seen whenever someone with MS is experiencing difficulties with walking. Problems with vision or sensation, which can make walking difficult, may only be temporary. A physician needs to treat these symptoms, or others such as spasticity, before sending a person to a physical therapist.
Seeing the physical therapist is the second, and equally important step, to improving any difficulties with walking. An individual alone cannot evaluate his or her problem, devise a correct exercise program, select and fit walking aids (if necessary), and use these devices properly.
Anyone who has never used a walking aid or wheelchair, or someone who may be considering a switch to a new device, may feel self-conscious about the change. While this is a natural response, keep in mind that the main idea is to preserve or gain back independence, while achieving optimum comfort, ease, and safety. Many people use these devices every day, and most businesses and public places are designed to accommodate them.
Eighty percent of individuals with MS will experience some type of physical discomfort at one time or another. About half experience some type of chronic pain attributable to the disease.
"Attributable to the disease" is the key phrase when referring to pain. Very often, people with a chronic condition tend to connect any symptom to their specific ailment – and those with MS are no exception. Pain with MS may be the result of a number of different causes.
When pain is experienced, the first thing to do is to see a physician to identify the source of the problem. An injury, infection, or other disturbance can easily produce discomfort or pain. Using painkillers that can hide a problem frequently results in a worsening of both the problem and the pain. The source of the pain needs to be found before an appropriate treatment plan may be prescribed.
When all other potential sources have been eliminated, and MS appears to be causing the pain, symptoms need to be closely examined to see what exactly is happening. Pain from MS is different from that of an injury or infection, as it results from abnormal nerve impulse flow in the CNS.
Many people with MS experience paresthesia. This may feel like a pressure, "pins and needles," or tingling sensation. Dysesthesia is a burning, throbbing, or shock-like pain along a nerve, often in the arms or legs but occasionally felt on the body as well. With dysesthesia, a light touch may become painful.
These symptoms may be no more than annoyances for many, but for some, treatment is needed to relieve the discomfort. Commonly used medicines for dysesthesia are tricyclic antidepressants and anticonvulsants such as gabapentin (Neurontin®), carbamazepine (Tegretol®) and phenytoin (Dilantin®).
Capsaic acid (Axsain®, Zostrix HP®) is a product available without a prescription. This cream may be applied three times daily and aids in relieving this type of pain. Made from hot pepper oils, capsaic acid appears to be safe and has few side effects.
Sometimes the pain may be the result of poor posture while sitting or walking. For example, poor posture can create a pinched nerve and cause lower-back pain. Therapies or devices may be used to correct the posture and consequently relieve the pain.
Less than five percent of people with MS experience "trigeminal neuralgia," also known as "tic douloureux." This condition causes a shock-like pain along the face, often triggered by a normal touch or movement, such as brushing the teeth, chewing, or touching a small area of skin. Antiseizure medications, gabapentin (Neurontin®), carbamazepine (Tegretol®) and phenytoin (Dilantin, Epanutin®) are often prescribed to treat this condition by relaxing or calming the nerves involved. Gabapentin is one of the most commonly prescribed medications for pain associated with MS.
Baclofen (Lioresal®) and tizanidine (Zanaflex®) may also be helpful. Misoprostol (Cytotec®) is another treatment option, but women who are pregnant may not take this medication.
Trigeminal neuralgia tends to come and go, enabling individuals to take medication on an as-needed basis. Should drug treatments fail, other options are available. These include procedures that numb the nerves, as well as surgery, although the latter is rarely necessary for this condition.
Spasticity and muscle spasms are other symptoms of MS that can create pain. Special exercise, devices, medication, and massage are a few of the ways spasticity and muscle spasms may be managed. These treatments are discussed in detail in a previous section devoted to spasticity.
The back, leg, and knees are common areas to experience pain. "L'hermitte's sign" is an electrical sensation which goes down the spine and into the legs when the neck is flexed forward. This sign of demyelination in the neck region is commonly found in those with MS, and is not significant in terms of MS severity, although it can be a disturbing sensation.
Many problems may be associated with the back among people with or without MS. Heat, massage, special exercise, and alternative therapies may prove helpful for back problems and pain. Chiropractic care (spinal manipulation) is thought by some physicians to be irritating to a patient's spinal cord and is not often recommended by many doctors who treat MS.
Drugs used for back pain include chlorzoxazone and acetaminophen (Parafon Forte®), cyclobenzaprine (Flexeril®), methocarbamol (Robaxin®), and arthritis medications. Surgery may be advisable for those with disc or structural problems.
Knee ligaments can become damaged from hyperextension while walking. This causes both inflammation and pain. Doctors not familiar with MS may prescribe exercise for this condition. Such therapy will only serve to increase tiredness and reduce leg strength. Often the correct treatment is to take the weight off of the leg with a cane or crutch while using a knee brace to prevent further hyperextension.
Gabapentin (Neurontin®) is the most commonly prescribed pain medication. Also an anti-seizure medication, this drug is typically started at a dose of 300 mg at bedtime, and is gradually increased to 300 to 400 mg three times daily until the pain has subsided. Side effects include sedation, fatigue, and dizziness, all of which may be reduced by decreasing the dose or by saving higher doses for evening.
Carbamazepine (Tegretol®), an anti-seizure medication frequently given for MS pain, is often accompanied by sleepiness, ataxia, and/or nausea when the drug is first taken. These side effects may be avoided by starting slowly and gradually building to an effective dosage – usually 300 mg to 400 mg three to four times daily.
A certain level of this medication must be kept constant in the bloodstream to continue its effectiveness. Blood levels must be checked regularly to guard against too much of this drug accumulating in the bloodstream. Those unable to tolerate this drug usually develop skin rashes and/or blood reactions. Blood and liver tests should be conducted and monitored periodically.
Phenytoin (Dilantin®) is similar to carbamazepine yet milder. This drug must also be taken on a regular basis to accumulate in the bloodstream before it can affect pain. Phenytoin is absorbed slowly, so (unlike carbamazepine) it may be started at a full dose, usually 100 mg three to four times daily or 300 mg to 400 mg one time daily.
People unable to tolerate phenytoin may become sedated or clumsy; they may walk with an unsteady gait, have slurred speech, or develop an allergy. Blood reactions may also occur. This medication is normally discontinued if signs of intolerance appear. Levels of this drug in the bloodstream must be regularly monitored.
Imipramine (Tofranil®) is a tricyclic antidepressant that has an effect on pain and is also used for bladder control problems. This drug can cause sedation, urinary retention, constipation, and dry mouth. Imipramine must be taken regularly for at least one week before results are seen.
Although the drugs mentioned help to alleviate pain, investigators don't know all the details as to why they work. Research continues seeking new classes of drugs to help fight pain.
With any of these drugs for pain, the lowest effective dosage should be used. Many of these medications may be used for years, if needed. Should symptoms subside for a few weeks, the medication may be slowly withdrawn to see if the pain has discontinued on its own. Always check with a physician before making any kind of a change with medication or dosage.
Prescribed painkillers such as meperidine (Demerol®), methadone, and morphine may help to alleviate chronic pain, but these are addictive and generally not recommended. Additional medications, such as aspirin, codeine, and certain narcotic analgesics are often not effective for pain in MS and are not usually given for this purpose.
Antidepressants or tranquilizers are occasionally prescribed for people experiencing pain. While depression does not create pain, pain can certainly lead to depression for some. These drugs can also alter how sensation is interpreted by the brain, often diffusing intense pain.
Tizanidine (Zanaflex®) is a medication often used to treat spasticity, but some neurologists are also using it for MS pain. Cannabis (marijuana) is another potential treatment for pain, although its use in MS is still controversial and unproven.
Transcutaneous Electric Nerve Stimulation (TENS) is another option for pain relief. TENS works by applying electric stimulation to a pain-related nerve. Delivered through the skin to the nerve, this procedure is sometimes able to block certain sensations of pain.
Some physicians claim TENS worsens MS symptoms, while others find it to be a viable alternative when more traditional therapies fail. The success of TENS varies according to the individual. Some experience relief, while others have been known to experience additional discomfort as a result of using TENS.
Surgery is another option for chronic pain that does not respond to traditional treatments. Details of nerve destruction (cutting the nerve) or chemical blocking of the nerve are given in a previous section under spasticity.
Spinal cord surgery or electric stimulation of the dorsal column of the spinal cord may be effective but are also dangerous and rarely performed. Some procedures use only lasers and local anesthesia to destroy the nerve and eliminate the pain, replacing it with numbness. Such processes are only to be considered after a prolonged period of pain, when all other methods of pain relief have been exhausted.
Aside from medical treatments, other therapies may be successful in the management of chronic pain. Many of these are safe and surprisingly simple.
Countering the present sensation with a different one can often make the pain tolerable. Pins and needles (paresthesia) may be relieved by bathing in lukewarm water. Immersing the affected area in cold or warmth usually produces some desirable effects. Applying pressure or massage can also alter some painful sensations.
Certain stretching exercises may be useful in temporarily relieving pain, and physical therapy may also help. Some achieve pain relief through alternative therapies such as acupressure, acupuncture, biofeedback, meditation, hypnosis, and therapeutic massage.
Please keep in mind that MS pain is not a predictor of a worse prognosis. Dwelling on pain and fearing it to be a sign of further disease progression will only make the pain feel more intense. Levels of pain have little to do with the severity and long-term outcome of MS.
When dealing with pain, the best strategy is to first seek medical attention and rule out other causes. Afterwards, various treatment options – including the ones just mentioned – may be discussed with the medical professional.
Additionally, social support may be beneficial to those who experience chronic pain. In addition to organized support groups, just seeing good friends or participating in enjoyable activities may help to diminish pain.