PharmSmart: Spasms vs Spasticity

By Seasons | September 08, 2021

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If I don’t learn the difference, I’m going to spazz!

“My patient has a spasm… or is it spasticity? What’s the difference?!” Despite their similarly sounding name, there is a difference between spasms and spasticity.

A spasm is the term for involuntary muscle contraction. Spasms may occur in skeletal muscle (think leg or thigh cramps) or smooth muscle (think bladder or GI cramps). It results from muscle sprain or injury or nerve compression.1 Muscle spasms are very common – most of us have experienced it at one time or another. Causes of skeletal muscle spasm may include dehydration, low back pain, spinal stenosis, fibromyalgia, or sciatica just to name a few.

On the other hand, spasticity is a motor disorder that results from velocity-dependent increase in muscle tone.2 Essentially, spasticity is over-activity in muscles. Causes of spasticity include multiple sclerosis, cerebral palsy, spinal cord injury and motor neuron disease.

Let’s take a look at a case

JM is a 63-year-old male with multiple sclerosis. His medical chart mentions symptoms of muscle stiffness and rigidity. He has been experiencing these symptoms for a number of years. JM uses baclofen to help control his symptoms.

Which does JM most likely have?

  1. Spasticity
  2. Spasm

Based on the fact that the patient has multiple sclerosis, A – spasticity, is the correct answer. You will soon learn that baclofen is used to treat spasticity, though sometimes it is also prescribed to patients for muscle spasms.

The incidence of spasticity varies based on the cause. For example, post-stroke spasticity occurs anywhere between 4% to 43% of patients.3 Conversely, spasticity occurs in up to 80% of those with multiple sclerosis, though reports and severity vary widely.4

Spasticity can cause muscle stiffness, tightness, or weakness, along with potentially involuntary movements. Other symptoms may include fatigue or painful joints as a result of the tightened muscle(s). Any muscle can be affected by spasticity; some of the most common include hamstrings, quadriceps, and biceps. Symptoms range from mild to severe and can affect movement and quality of life.5 A patient with spasticity may experience complications like pressure sores, chronic constipation, or urinary tract infections.6

Though pharmacologic therapy is the mainstay, treatment of spasticity often requires a multimodal approach utilizing non-pharmacologic therapies. Spasticity generally results from an underlying condition, however, other modifiable factors may contribute to worsened symptoms. Therefore, it is important to identify any patient-specific and modifiable factors and treat them appropriately. Are they dehydrated? Were they in the same position for a prolonged period of time? Are they getting adequate rest? These are questions you should be asking yourself or your patients. Other treatment options include physical or occupational therapy, and some patients may even require surgical intervention.2,7

Recall, spasticity results from increased muscle tone. Antispastic agents work to decrease muscle tone by blocking nerve signaling that originates in the spinal cord. See the below table for more information on specific agents.

Now, onto spasms…

While the incidence of spasms is not fully elucidated in patients receiving palliative or hospice care, the frequency generally increases as we age.1,8 Like spasticity, muscle spasms produce symptoms ranging from mild discomfort to severe pain. Muscles may feel tight or even hardened. Spasms are typically short in duration, but some individuals may experience a single spasm or a recurrence of spasms over a short period of time. Thankfully, muscle spasms are generally benign and can be prevented (or treated) fairly easily.

A variety of non-pharmacologic treatments may be utilized to treat or prevent muscle spasms, including adequate hydration, stretching, exercise, massage, and temperature therapy.2 If conservative measures are inadequate, use of an antispasmodic can be considered. As their name suggests, they work to relieve involuntary muscle spasms, making them the perfect agents!

Generic (Brand)

Dose

Max Dose/ Duration

Additional Info

Antispasmodic Agents*9,10

Carisoprodol (Soma)

250-350 mg TID + HS

Dose: Not stated

Duration: 2-3 weeks

Taper slowly if used at high doses or long-term

Cyclobenzaprine (Flexeril)

5-10 mg TID

Dose: Not stated

Duration: 2-3 weeks

Strong anticholinergic properties

Metaxalone (Skelaxin)

800 mg TID or QID

Dose: Not stated

Duration: Not stated

Strong anticholinergic properties

Methocarbamol (Robaxin)

1500 mg TID or QID for 2-3 days, then 4-4.5g in 3-4 divided doses

Dose: Not stated

Duration: Not stated

 

Causes skeletal muscle relaxation by CNS depression

Orphenadrine (Norflex)

100 mg BID

Dose: Not stated

Duration: Not stated

Strong anticholinergic properties

Dicyclomine (Bentyl)

20 mg up to 4 times daily

Dose: Not stated

Duration: Not stated, intended for short-term use

Primarily used for GI spasms; Contraindicated in obstructive GI diseases

Antispastic Agents8,9

Baclofen (Lioresal)

5 mg TID; titrate by 5 mg every 3 days

Dose: 80 mg/day (some may require higher doses)

Duration: Not stated

Abrupt discontinuation is associated with withdrawal; May be used off-label for muscle spasms

Dantrolene (Dantrium)

25 mg QD; titrate to effect every 7 days

Dose: 400 mg/day

Duration: 45 days if no benefit

BBW for hepatotoxicity

Combination Agents9,10

Diazepam (Valium)

<65: 2 mg BID or 5 mg HS

>65: 2 mg-2.5 mg QD or BID; titrate as necessary

Dose: 40-60mg/day

Duration: Not stated

 

BBW for concomitant use with opioids, abuse, misuse and addition, and dependence and withdrawal risk

Tizanidine (Zanaflex)

2 mg-12 mg QD to TID; titrate as necessary

Dose: 36 mg

Duration: Not stated

Taper gradually to reduce rebound symptoms (e.g. hypertension, tachycardia, hypertonia)

*While some agents have specific durations for use, it is important to note that use of antispasmodics should be limited to 2-3 weeks if possible. Further, many of the above agents are contained on the Beer’s List and thus should generally be used with caution.

Patient Case – AJ

AJ is a 30-year-old female with no significant medical history. She went for a run in 97-degree weather and is now experiencing spasms. What are some conservative non-pharmacologic treatment options for AJ?

  1. Hydration
  2. Massage
  3. Stretching
  4. B and C only
  5. All of the above

If you answered all of the above, you are correct! Since she was running on a hot day, hydration and stretching are important. Massage of the affected muscle may also be useful, especially after exercise. A few weeks later AJ goes to her PCP as she is still experiencing muscle spasms regularly. The doctor asks you what medication (along with dose and frequency) you recommend. What is the best option?

  1. Dantrolene 25 mg QD

  2. Diazepam 10 mg QHS

  3. Flexeril 5 mg TID PRN spasms

  4. Orphenadrine 200 mg BID

Answer choice C is the best option as it is the appropriate medication and regimen. Dantrolene is used for spasticity, so that option should be avoided. Diazepam and orphenadrine could be used for spasms, however, the initial doses provided are incorrect. Ten years later you see AJ and learn that she has been diagnosed with MS. She has developed spasticity. What therapy would be an appropriate option?

  1. Baclofen

  2. Tizanidine

  3. Dantrolene

  4. Diazepam

This one was tricky! While technically all the above answers can be used for spasticity, baclofen is typically the first line option. Given she has not been on other treatment, baclofen would be an appropriate option for AJ. When starting baclofen it would be appropriate to start at 5 mg TID and titrate to effect. If a patient still has uncontrolled symptoms at the highest dose (80 mg/day or even higher in some) then we would want to consider alternatives.

Patient Case – TJ

TJ is a 77-year-old male that has been admitted to hospice following a diagnosis of stage IV lung cancer. Today he told you (the guru on spasms versus spasticity) that he is experiencing some cramping and a burning sensation in his bladder. When he has these feelings, he notices that he has a small amount of urination. They come so quickly he is unable to go to the bathroom and often doesn’t realize what has happened until he notices his pants are wet. What agent would be appropriate for TJ?

  1. Tizanidine
  2. Dantrolene
  3. Dicyclomine
  4. Carisoprodol

In this case, C – dicyclomine, would be the best option as its best for spasms involving the GI and bladder, or areas with smooth muscle. This would also be an appropriate option for someone experiencing GI cramps from irritable bowel syndrome, for example.

Self-Assessment Questions

 
1. After how many days should dantrolene be discontinued if the patient is not experiencing any benefit?
  1. 7 days

  2. 3 days

  3. 45 days

  4. 30 days

  5. 10 days

  1. SA is a 68-year-old male who is experiencing spasms after lifting a heavy box. What agent(s) may be appropriate for initial treatment?

  1. Orphenadrine

  2. Dantrolene

  3. Carisoprodol

  4. A and C only

  5. All the above

  1. Abrupt discontinuation of which antispasmodic or antispastic agent may lead to hypertension, hypertonia, and tachycardia?

  1. Baclofen

  2. Tizanidine

  3. Diazepam

  4. Methocarbamol

  5. Metaxalone

Answers: 1 C; 2 D; 3 B

Because this newsletter focused on oral treatment, if you are interested in learning about other treatments for spasticity such as intrathecal baclofen and botulinum toxin injection, check out the following article:

Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, Mozaffar T. A review of spasticity treatments: pharmacological and interventional approaches. Crit Rev Phys Rehabil Med. 2013;25(1-2):11-22.

References

  1. Muscle Spasms. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/15466-muscle-spasms. Updated March 11,2021. Accessed July 10, 2021.
  2. Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, Mozaffar T. A review of spasticity treatments: pharmacological and interventional approaches. Crit Rev Phys Rehabil Med. 2013;25(1-2):11-22.
  3. Wissel J, Manack A, Brainin M. Toward an epidemiology of poststroke spasticity. Neurology. 2013;80:13-19.
  4. Rizzo MA, Hadjimichael OC, Preiningerova J, Vollmer TL. Prevalence and treatment of spasticity reported by multiple sclerosis patients. Mult Scler. 2004;10(5):589-595.
  5. Spasticity Information Page. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/All-Disorders/Spasticity-Information-Page. Accessed July 10, 2021.
  6. American Association of Neurological Surgeons. https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spasticity. Accessed July 11, 2021.
  7. Peckel L. Nonpharmacologic approaches to spasticity management. Neurology Advisor. https://www.neurologyadvisor.com/topics/movement-disorders/nonpharmacologic-approaches-to-spasticity-management/. Updated January 29, 2019. Accessed July 11, 2021.
  8. Muscle Cramps and Spasms. MUSC Health. https://muschealth.org/medical-services/geriatrics-and-aging/healthy-aging/cramps-and-spasms. Accessed July 11, 2021.
  9. Trueman C, Castillo C, O’Brien KK, Hoie E. Inappropriate use of skeletal muscle relaxants in geriatric patients. US Pharm. 2020;45(1):25-29.
  10. Individual agents. In: Lexi-Drugs. Hudson, OH: Lexicomp, Inc. Accessed July 10, 2021.
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