Neurology: Managing Spasticity

Spasticity, an abnormal function of the muscles that can present itself in many ways, is an unpleasant, often painful condition that can severely affect the quality of life of those who experience it. There’s no known cure for spasticity or the pain associated with it, and while medication and lifestyle interventions can help, patients and providers alike are beginning to look to alternative therapies to bring comfort and relief. Just as acupuncture and aquatic therapies have been embraced, cannabis interventions are being explored as viable options for both spasticity and pain relief.

But what does the science say? Is there enough evidence to recommend the use of cannabinoid therapies to manage, or even control, spasticity symptoms?

What Is Spasticity?
Many people associate sore muscles and stiff joints with the natural aging process, but some individuals find over time that those complaints may result from more than just aging. Increased stiffness of the muscle or muscle tone is known as spasticity. It’s an abnormal increase in muscle stiffness and is often accompanied by discomfort. Commonly associated with multiple sclerosis (MS), spasticity also occurs in patients with many other disorders, such as motor neuron disease, cerebral palsy, spinal cord injury, and stroke. Researchers at the National Institute of Neurological Disorders and Stroke believe that spasticity is a result of damaged nerve pathways in the brain and spinal cord that control muscle movement.1 Not only can spasticity be painful but it can also interfere with the quality of daily life for those who experience it. The often uncontrollable symptoms include rapid muscle contractions, involuntary crossing of the legs, contractions that stiffen joints, and muscle spasms.

There’s no cure for these neurological conditions, so the ultimate treatment goal is to provide symptom relief. Current treatment options for spasticity include prescription medication interventions along with physical therapy and rehabilitation. The treatment options are determined based on the severity of the disorder and the unique circumstance of each individual. The goal is to relieve pain and prevent the condition from becoming worse. Common prescription medications include baclofen, diazepam, tizanidine, and clonazepam.1 Lifestyle interventions include physical therapy sessions to increase range of motion and muscle mobility and holistic interventions such as guided imagery, deep breathing, acupuncture, and aquatic therapy. In extreme situations, surgery may be recommended on a case-by-case basis.

Can Cannabis Help?
While there are a variety of treatment options available to treat spasticity, those who suffer from this debilitating condition are still looking for a way to reduce their pain and increase their quality of life. Additionally, it has been reported that despite the drug interventions available to relieve spasticity, “evidence for their effectiveness is scant and they do not sufficiently improve symptoms in all patients.”2 Not only are these drugs questionably effective but they are often accompanied by unwanted side effects such as fatigue. As cannabis legalization sweeps the country and more neurological conditions are being treated with cannabinoid medicine, many patients are becoming increasingly interested in what cannabis can provide in terms of pain relief and muscle control. While more clinical research is needed to prove the efficacy of cannabis for spasticity treatment, some preliminary data suggest a positive outcome.

A study published in The Lancet Neurology Journal tested the efficacy of two compounds derived from the cannabis plant in an oral spray as an add-on treatment to ease the symptoms of spasticity—THC and CBD. This trial studied 60 adults in total, one-half of whom were given the cannabis oral spray, while the other half, the control group, received a placebo oral spray. They were encouraged to use the spray several times a day, with the dose gradually increasing over time. At the end of the six-week study, those individuals who had received the THC:CBD spray reported that their spasticity symptoms were “significantly improved” compared with the placebo group. The THC:CBD group also reported a significant improvement in their perception of pain.2 Overall, the THC:CBD spray was well tolerated by the participants, and the positive outcomes suggest the need for further research.

Research from an observational study presented at the 2019 American Academy of Neurology Annual Meeting is even more promising, showing cannabis as an effective treatment option for spasticity. This long-term study, which followed more than 1,800 Italians living with resistant MS spasticity, studied the efficacy of a THC:CBD oromucosal spray (Sativex) over a course of 18 months. All participants were instructed to assess their spasticity symptoms on a numerical 0–10 scale at one month, six months, 12 months, and 18 months. The data collected from this real-life observational study “confirmed the long-term effectiveness of THC:CBD for the treatment of resistant MS spasticity.”3

Overall, however, evidence for the efficacy of cannabis for spasticity remains mixed. Thirty-two papers published in Practical Pain Management between 2006 and 2014 examining the use of cannabinoids for the treatment of MS-related spasticity and pain were reviewed, demonstrating mixed results for both pain relief and spasticity relief. In most cases, improvements were self-reported by patients, and the researchers were unable to draw conclusions due to insufficient or questionable evidence.4

A lack of clinical research in the United States has not stopped the progression of medical cannabis use for spasticity attributed to MS in other countries. According to the Expert Review of Neurotherapeutics in 2020, “medical use of marijuana smoking has bypassed traditional clinical trials and has been legalized as a therapeutic option for MS-related spasticity and pain in some countries.” Alongside smoking, the United Kingdom has developed a drug known as nabiximol, making it “possible for patients with MS to have legal access to cannabis-related therapies.”5 This oromucosal spray was designed specifically to alleviate neuropathic pain, spasticity, overactive bladder, and other symptoms related to MS.

It’s important to note that one common finding in all these studies is that many participants experienced adverse side effects associated with cannabis consumption, such as fatigue, vertigo, and worsening cognitive symptoms. In some cases, participants discontinued their cannabis use altogether. This supports the idea that cannabis medicine is not right for everyone or every circumstance.

What Clinicians Need to Know
Despite the lack of long-term clinical trials to support the use of cannabis for spasticity (related to MS or other causes), it’s still a popular pain-management option for both medical and recreational consumers. One six-month online web survey hosted on the Michael J. Fox Foundation and the National Multiple Sclerosis Society webpages conducted in 2016 found that “24% of 595 respondents reported overall high efficacy of cannabis use” for their symptoms.6 Equally important, “59% reported reducing prescription medication since beginning cannabis use.” This anecdotal evidence supports the theory that cannabis can be a useful tool in improving the quality of life for individuals who suffer from spasticity. Clinicians will likely encounter patients who choose to use cannabis to manage their symptoms of spasticity and pain, regardless of their source. As always, it’s important for clinicians to treat the patient, not the condition. As each person’s endocannabinoid system is unique, so is the regimen needed to support it. The clinician should work with patients to provide the education and guidance needed to help them explore different consumption methods and dosages and remind them they’ll likely need to be patient and willing to experiment to find a regimen that’s just right for them and their unique circumstances.

Conclusion
As for most conditions, clinical evidence lags far behind the anecdotal evidence to support the use of cannabinoid therapies for the treatment of spasticity and spasticity-related pain. Researchers in countries such as the United Kingdom and Italy are leading the charge in the study of cannabis-related therapies that could bring much needed relief to patients who live with these uncomfortable conditions. While more research is needed, it’s important for clinicians to be open-minded to cannabis therapies, which are the preferred medication of choice for many patients seeking an improved quality of life.

— Emily Kyle, MS, RDN, CDN, CLT, HCP, is a certified holistic cannabis practitioner.

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