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Treatment for spasticity (muscle tightness and spasm) in people with amyotrophic lateral sclerosis/motor neuron disease

Spasticity commonly causes a 'stiffness' or 'tightness' in the already weakened muscles of a person with amyotrophic lateral sclerosis (also known as motor neuron disease). This can lead to even greater difficulties in the ability to perform day‐to‐day activities. This review found only one randomized trial of treatment for spasticity in motor neuron disease, which involved 25 participants, and no further trials have been found in subsequent updates. There were a number of issues with the design of the study which unfortunately reduced the certainty of the findings. At three months participants performing the 15 minute twice daily exercises had significantly less spasticity overall than control participants (mean reduction of ‐0.43, 95% confidence interval (CI) ‐1.03 to +0.17 in the treatment group versus an increase of +0.25, 95% CI ‐0.46 to +0.96 in control) but the mean change between groups was not significant, as measured by the Ashworth scale (a scale of spasticity, with a range of 0 to 5, where higher is worse). The trial was too small to determine whether individualized moderate intensity endurance type exercises for the trunk and limbs are beneficial or harmful. No side effects from exercise were reported. No other randomized trials of different treatments or therapies were found. Further research is needed to determine if exercise or other therapies such as anti‐spasticity medication are beneficial or harmful.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Not enough evidence about the effects of drugs used to try and reduce spasticity in the limbs after spinal cord injury

A major problem after spinal cord injury is muscle resistance to having the arms or legs moved (spasticity). There can also be spasms. This can severely limit a person's mobility and independence, and can cause pain, muscle problems, and sleep difficulties. Treatments to try and reduce spasticity include exercise, and drugs to try and decrease the muscle tone. The review found there was not enough evidence from trials to assess the effects of the range of drugs used to try and relieve spasticity after spinal cord injury. The authors of the review call for more research and make recommendations as to how this research should be conducted.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Non pharmacological interventions for treatment of spasticity in Multiple Sclerosis (MS)

Spasticity is a common and debilitating symptom, causing ‘stiffness’, ‘spasms’ or ‘tightness’ in the weakened arm or leg in people with multiple sclerosis (MS). Overall, spasticity is difficult to treat. Current treatments include various medications (such as botulinum toxin injections to relax the affected muscles) and non drug methods aiming to achieve functional goals for patients (and their caregivers) such as physiotherapy, magnetic stimulation, electromagnetic therapy, vibration therapy. In this review, nine studies evaluating various non drug treatments to treat spasticity in adult with MS were included, comprising a total of 341 participants. Results from these studies suggest that all included non pharmacological therapies have low level of evidence or no evidence in improving spasticity in people with MS. However, caution should be used in the interpretation of the results, due to the poor methodological quality of all the included studies. More research is needed to determine the usefulness of these interventions before they can be recommended as routine treatments.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

The effect of anti‐spasticity agents in people with multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the nervous system which affects young and middle‐aged adults. Spasticity, a common problem in people with MS, is a disorder of voluntary movement caused by damage to the central nervous system. The main sign is the resistance to passive movement of a limb but other associated features ‐ pain, spasms, loss of function ‐ affect people's quality of life more directly.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Multidisciplinary rehabilitation programmes following treatment of spasticity after stroke

Stroke can cause muscle stiffness, spasms or tightness in the affected arm or leg, with pain and abnormal positioning of the limb. Consequently, there may be difficulties using the arm or leg in everyday activities or in caring for the affected limb. Treatments for spasticity may include botulinum toxin and other injected medications that paralyse the affected muscles. Following such injections, a multidisciplinary (MD) rehabilitation programme (usually delivered by two or more health professionals) is often employed. Interventions may include stretching, splinting, gait training, repetitive practice in using the arm for tasks, and orthotic prescription. Therapies are aimed at reducing spasticity to improve limb use or positioning, or to make it easier to care for the affected limb. The outcomes of such programmes focus on attainment of functional goals that are important to affected people in their everyday life. We included three relevant studies in the review, which investigated different types of MD rehabilitation interventions after botulinum toxin injections into the arms of 91 adults with previous stroke. There was low quality evidence for intensive forced use of the affected arm in improving spasticity, and very low quality evidence for elbow splinting with occupational therapy. We did not identify any studies of MD rehabilitation in children with post‐stroke spasticity or after other injected medications. The review findings are limited by the small number of studies that are methodologically flawed. More research is needed into what rehabilitation modalities and treatments are most effective for spasticity management following stroke.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Comparing Muscle Relaxants

How do muscle relaxants compare in treating spasticity caused by a neurological disorder?

PubMed Clinical Q&A [Internet] - National Center for Biotechnology Information (US).

Version: December 1, 2007

Botulinum toxin type A injections for the treatment of lower limb spasm in cerebral palsy

Cerebral palsy (CP) is a non‐progressive lifelong condition resulting from damage to the newborn brain. Most infants have spasms (spasticity) affecting at least one leg that prevents normal movement. It can cause muscle contractures and deformities and the affected muscles do not grow as rapidly as neighbouring bone and soft tissue. Treatment includes physiotherapy, oral anti‐spasticity drugs, casts, splints and orthopaedic surgery. Injection of botulinum toxin (BtA) into muscle causes local muscle weakness and so may help counter spasticity. This review found that published, controlled evidence was weak as they identified three controlled trials involving only a small number of children (2 to 11 years). Children receiving a single course of injections of BtA (Botox®, 3 to 8 µg/kg or Dysport®, 15 µg /kg) into the calf muscle tended to have an improved pattern of walking (gait) compared with inactive injections (placebo). Both BtA injections and lightweight walking plaster casts below the knee (for four to six weeks) produced similar significant improvements in gait. Some calf pain was reported among the 26 children injected with BtA and parents reported inconvenience with wearing casts and weakness of legs following removal.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

There is high level evidence to support the safety and effectiveness of Botulinum toxin ‐A (BoNT‐A) as an adjunct to managing the upper limb in children with cerebral palsy.

When injected into muscles BoNT‐A reduces muscle tightness. When used in conjunction with occupational therapy, the aim of BoNT‐A injections in the arms and hands is to improve movement and function in treated limbs. This review demonstrated improvements on a range of measures with the combined treatment. In the absence of significant side effects, injection of BoNT‐A has been identified as a safe and effective treatment for upper limb spasticity when used in combination with occupational therapy in children with cerebral palsy.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Intrathecal baclofen for treating spasticity in children with cerebral palsy

Spasticity, which is an increase in muscle tone, is the most common difficulty with movement seen in children with cerebral palsy. Baclofen is a medication which acts on receptors in the brain and spinal cord to reduce abnormal muscle tone. It has been used as an oral medication for many years. The disadvantages of oral administration are that only a small amount of the medication crosses the blood‐brain barrier before it can exert an effect, and that the dose is limited by the unwanted effect of excessive sedation. The administration of baclofen into the fluid surrounding the spinal cord overcomes these problems. This treatment is called intrathecal baclofen therapy and it is administered via a pump placed under the skin connected to a catheter which enters the membranes covering the spinal cord to deliver the baclofen directly into the fluid surrounding the spinal cord and brain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Drugs (with the exception of botulinum toxin) to treat spasticity after stroke

We wanted to learn whether there was evidence for using drugs for spasticity in people with stroke, and if so, to identify whether drugs that acted on the whole body (systemic drugs) differed in their effects to drugs that acted in a localised area of the body (local drugs).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Is stretch effective for treating and preventing joint deformities?

Review question: we reviewed the evidence about the effect of stretch in people who had or were vulnerable to joint deformities.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Passive movements for the treatment and prevention of contractures

This Cochrane systematic review determines the effects of passive movements for contractures.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Managing symptoms in motor neuron disease

Motor neuron disease (MND), which is also known as amyotrophic lateral sclerosis (ALS), is an uncommon, incurable disease that affects the nerves involved in movement. MND gets worse over time and affects muscles of the limbs, speech, swallowing and breathing. People with MND experience a wide range of symptoms, including a number of physical ability limitations, pain, spasticity, cramps, swallowing problems and difficulty breathing. It is important to recognise that clinical trials may fail to show that a treatment is effective for several reasons that are not related to the effects of the treatment itself, for example when there are too few people in a trial, or investigators choose an ineffective dose of a drug.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Electrical stimulation for preventing and treating post‐stroke shoulder pain

Electrical stimulation of muscles improves shoulder stiffness after a stroke but there is not enough evidence to prove whether it reduces shoulder pain. Patients who have a stroke (a sudden catastrophe in the brain either because an artery to the brain blocks, or because an artery in or on the brain ruptures and bleeds) often develop shoulder pain. This adds to the difficulties caused by the stroke. Pain in the shoulder can cause weakness, loss of muscle tone and loss of feeling. Electrical neuromuscular stimulation (ES) is done by applying an electrical current to the skin. This stimulates nerves and muscle fibres and may improve muscle tone, muscle strength, and reduce pain. The review found that shoulder stiffness improved after ES. No adverse effects were noted. The review also found there was not enough evidence to decide if ES can reduce shoulder pain or not. More research is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Botulinum toxin for shoulder pain

This summary of a Cochrane review presents what we know from research about the effects of botulinum toxin on shoulder pain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Occupational therapy as supportive treatment for people with multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the nervous system which affects young and middle‐aged adults. MS causes disruption of the ability of nerves to conduct electrical impulses, leading to symptoms such as muscle weakness, fatigue and loss of control over the limbs. Occupational therapy (OT) is used to try to help people with MS participate in the physical and social activities of their daily lives. The review found that there is currently no reliable evidence that OT improves outcomes for people with MS, although there was some suggestion that fatigue might be improved.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

D‐Penicillamine for preventing retinopathy of prematurity in preterm infants

Retinopathy of prematurity (ROP) is an eye disease of premature infants that continues to be a serious problem. The drug D‐penicillamine, given by mouth, is commonly used to treat poisoning by iron or copper or other heavy metals. In research studies of D‐penicillamine used for another problem that premature infants have (high bilirubin), it was observed that the treated infants had less ROP. However, this systematic review did not show any significant benefits of this drug for the outcomes of ROP, death or development of nerves. Thus, the use of this drug cannot be recommended for the prevention of ROP based on available evidence.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Surgery for cervical radiculomyelopathy

Cervical spondylosis, or degeneration (wear and tear of the bones and discs in the neck), is a very common condition affecting most of us at some point in our lives. It is frequently related to strain of the supporting muscles or wear and tear of the discs that connect the individual bones (vertebrae) that form the spine, resulting in neck pain. Radiculopathy is pain, weakness or reduced reflexes that follow the path of nerves that come from the neck region. Myelopathy is spasticity and weakness in the lower limbs with or without "numb and clumsy" hands.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Herbal medicine for cervical degenerative disc disease

Two Chinese oral herbal medications were tested in three randomized controlled trials that included 701 adults with chronic neck pain with radicular signs or symptoms or myelopathy. One oral herbal medication was compared with Mobicox (non‐steroidal anti‐inflammatory medication) and Methycobal (drug to reduce numbness, tingling in the arms), and the other (Compound Qishe Tablet) with placebo and Jingfukang. A topical herbal medicine (Compound Extractum Nucis Vomicae) was compared with Diclofenac Diethylamine Emulgel (non‐steroidal anti‐inflammatory medication).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Constraint‐induced movement therapy for upper limb (arm) recovery after stroke

We wanted to assess the effects of constraint‐induced movement therapy (CIMT) on ability to manage daily activities and on the recovery of movement in paralysed arms after a stroke.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

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