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Abd-Nikfarjam B, Dolati-Somarin A, Baradaran Rahimi V, Askari VR. Cannabinoids in neuroinflammatory disorders: Focusing on multiple sclerosis, Parkinsons, and Alzheimers diseases. Biofactors 2023. [PMID: 36637897 DOI: 10.1002/biof.1936] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023]
Abstract
The medicinal properties of cannabis and cannabinoid-derivative are entirely investigated and known. In addition, the identification of psychotropic plant cannabinoids has led to more studies regarding the cannabinoid system and its therapeutic features in the treatment and management of clinical symptoms of neuroinflammatory disorders, such as multiple sclerosis (MS), Parkinsons disease (PD), and Alzheimers disease (AD). In fact, cannabinoid agonists are able to control and regulate inflammatory responses. In contrast to the cannabinoid receptor type 1 (CB1) and its unwanted adverse effects, the cannabinoid receptor type 2 (CB2) and its ligands hold promise for new and effective therapeutic approaches. So far, some successes have been achieved in this field. This review will discuss an outline of the endocannabinoid system's involvement in neuroinflammatory disorders. Moreover, the pharmacological efficacy of different natural and synthetic preparations of phytocannabinoids acting on cannabinoid receptors, particularly in MS, PD, and AD, will be updated. Also, the reasons for targeting CB2 for neurodegeneration will be explained.
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Affiliation(s)
- Bahareh Abd-Nikfarjam
- Department of Immunology, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Reza Askari
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
- Pharmacological Research Center of Medicinal Plants, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Smith KA, Piehl F, Olsson T, Alfredsson L, Hillert J, Kockum I, Stridh P, Montgomery S. Spasticity treatment patterns among people with multiple sclerosis: a Swedish cohort study. J Neurol Neurosurg Psychiatry 2022; 94:337-348. [PMID: 36539267 PMCID: PMC10176386 DOI: 10.1136/jnnp-2022-329886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Spasticity is common among people with multiple sclerosis (MS), but there are few studies of spasticity treatment patterns. We aim to describe associations with spasticity treatment measured primarily by oral baclofen use. METHODS This cohort study using Swedish registers included 1826 and 3519 people with incident and prevalent MS (pwIMS, pwPMS) respectively, followed from 2005 to 2014. Cox regression assessed factors associated with new baclofen prescriptions and its discontinuation. RESULTS A total of 10% of pwIMS and 19% of pwPMS received baclofen, a drug prescribed specifically for spasticity in Sweden, of which many patients had relapsing-remitting course. Prescriptions occurred soon after MS diagnosis: pwIMS received baclofen typically within 6 months of diagnosis, and pwPMS within 3 years. Younger patients compared with older patients were three times more likely to receive baclofen with similar disability level measured using Expanded Disability Severity Scores (EDSS). Patients aged 18-44 years with EDSS 3.0-5.0 have an HR for baclofen use of 5.62 (95% CI 2.91 to 10.85) and EDSS 6+ have an HR of 15.41 (95% CI 7.07 to 33.58) compared with individuals with EDSS 0-2.5. In comparison, patients aged 45+ years with EDSS 3.0-5.0 have an HR of 2.05 (95% CI 1.10 to 3.82) and EDSS 6+ a hour 4.26 (95% CI 1.96 to 9.17). Baclofen discontinuation was high: 49% (95% CI 0.42 to 0.57) of pwIMS discontinued within 150 days of dispensation, 90% discontinued within 2 years including patients with progressive course or higher EDSS. Associations among pwPMS and sensitivity analyses including additional treatments were similar. CONCLUSIONS Younger patients with MS are more likely to receive baclofen compared with older patients with MS. High rates of baclofen discontinuation highlight the need for more tolerable and efficacious spasticity treatments and monitoring of spasticity among people with MS.
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Affiliation(s)
- Kelsi A Smith
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
| | - Fredrik Piehl
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre of Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden.,Academic Specialist Centre, Centre of Neurology, SLSO, Stockholm, Sweden
| | - Tomas Olsson
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre of Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden.,Academic Specialist Centre, Centre of Neurology, SLSO, Stockholm, Sweden
| | - Lars Alfredsson
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre of Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden.,Centre of Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Jan Hillert
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre of Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ingrid Kockum
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Stridh
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Scott Montgomery
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden.,Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
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Neurorehabilitation in Multiple Sclerosis-A Review of Present Approaches and Future Considerations. J Clin Med 2022; 11:jcm11237003. [PMID: 36498578 PMCID: PMC9739865 DOI: 10.3390/jcm11237003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Multiple sclerosis is an increasingly prevalent disease, representing the leading cause of non-traumatic neurological disease in Europe and North America. The most common symptoms include gait deficits, balance and coordination impairments, fatigue, spasticity, dysphagia and an overactive bladder. Neurorehabilitation therapeutic approaches aim to alleviate symptoms and improve the quality of life through promoting positive immunological transformations and neuroplasticity. The purpose of this study is to evaluate the current treatments for the most debilitating symptoms in multiple sclerosis, identify areas for future improvement, and provide a reference guide for practitioners in the field. It analyzes the most cited procedures currently in use for the management of a number of symptoms affecting the majority of patients with multiple sclerosis, from different training routines to cognitive rehabilitation and therapies using physical agents, such as electrostimulation, hydrotherapy, cryotherapy and electromagnetic fields. Furthermore, it investigates the quality of evidence for the aforementioned therapies and the different tests applied in practice to assess their utility. Lastly, the study looks at potential future candidates for the treatment and evaluation of patients with multiple sclerosis and the supposed benefits they could bring in clinical settings.
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Filippini G, Minozzi S, Borrelli F, Cinquini M, Dwan K. Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis. Cochrane Database Syst Rev 2022; 5:CD013444. [PMID: 35510826 PMCID: PMC9069991 DOI: 10.1002/14651858.cd013444.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti-spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required. OBJECTIVES To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant-derived cannabinoids, for reducing symptoms for adults with MS. SEARCH METHODS We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews. SELECTION CRITERIA We included randomised parallel or cross-over trials (RCTs) evaluating any cannabinoid (including herbal Cannabis, Cannabis flowers, plant-based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale-Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health-Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence. MAIN RESULTS We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female. The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of Cannabis sativa (2 studies), inhaled herbal Cannabis (1 study) against placebo. One study compared dronabinol, THC extract of Cannabis sativa and placebo, one compared inhaled herbal Cannabis, dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I2 = 67%; moderate-certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low-certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low-certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate-certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD -0.08, 95% CI -0.17 to 0.02; 8 studies, 1942 participants; I2 = 0%; low-certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low-certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low-certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low-certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Compared with placebo, nabiximols probably reduces the severity of spasticity in the short-term in people with MS. We are uncertain about the effect on chronic neurological pain and health-related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short-term duration of the included studies.
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Affiliation(s)
- Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Francesca Borrelli
- Department of Pharmacy, School of Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Michela Cinquini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Kerry Dwan
- Review Production and Quality Unit, Editorial & Methods Department, Cochrane Central Executive, London, UK
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Salarvand S, Heidari ME, Farahi K, Teymuri E, Almasian M, Bitaraf S. Effectiveness of massage therapy on fatigue and pain in patients with multiple sclerosis: A systematic review and meta-analysis. Mult Scler J Exp Transl Clin 2021; 7:20552173211022779. [PMID: 34188950 PMCID: PMC8209836 DOI: 10.1177/20552173211022779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Fatigue and pain are prevalent symptoms of multiple sclerosis (MS) and frequent complaint in MS patients, which reduce their quality of life. This study aimed to assess the effect of massage therapy on pain and fatigue in MS Patients. Method The original and Persian databases were searched included PubMed, web of science, embase, ovid, scopus, and the Cochrane Library, SID, and Iranedex from inception to November 2020. Studies that reported the effect of massage on fatigue and pain were included. Two investigators extracted all relevant data, independently. For deriving analysis, mean difference (MD) and standardized mean difference (SMD) were used. Result Ten studies were eligible acoording criteria. The effect of massage on fatigue showed significant improvement (-1.62; 95% CL -2.40, -0.83; p < .00001), also results of the systematic review showed a significant reduction in pain severity. Conclusion Massage as a complementary and non-pharmacological therapy might have been associated with alleviating fatigue and pain in M.S. patients. Based on the current study, massage intervention for MS patients could have possible clinical value for palliating pain and fatigue and improving quality of life; however, this matter needs further and more significant trial studies.
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Affiliation(s)
- Shahin Salarvand
- Hepatitis Research Center, Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Mohammad Eghbal Heidari
- Student Scientific Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Farahi
- Student Scientific Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Teymuri
- Student Scientific Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Almasian
- Department of the English Language, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Saeid Bitaraf
- Department of Epidemiology and Biostatistics, Iran University of Medical Sciences, Tehran, Iran
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Sartori A, Dinoto A, Stragapede L, Mazzon G, Morelli ME, Pasquin F, Bratina A, Bosco A, Manganotti P. Nabiximols and botulinum toxin injections for patients with multiple sclerosis: efficacy on spasticity and spasms in a single-centre experience. Neurol Sci 2021; 42:5037-5043. [PMID: 33742336 DOI: 10.1007/s10072-021-05182-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spasticity is a common and disabling symptom in patients with multiple sclerosis (PwMS): as highlighted by many epidemiological studies, it is often a severe and not well treated. Despite the availability of evidence-based spasticity management guidelines, there is still great variability in everyday therapeutic approach, especially for the most complex cases. METHODS In our single-centre study, we retrospectively evaluated PwMS-treated nabiximols and botulinum toxin injections (BTI) from July 2015 to April 2019. Clinical and demographic data were collected. The severity of spasticity and spasms was recorded by modified Ashworth Scale (mAS) and Penn Spasm Frequency Scale (PSFS) at baseline and after 1 month of treatment. RESULTS We evaluated 64 treatments for MS-related spasticity: 28 patients were treated with BTI and 36 patients with nabiximols. We found that both BTI and nabiximols are effective in reducing mAS (nabiximols, BTI: p < 0.001), PSFS frequency (nabiximols: p = 0.001, BTI: p = 0.008) and intensity (nabiximols: p = 0.001, BTI p = 0.016). No differences were found when directly comparing the efficacy of the two treatments, except for a statistical trend favouring BTI on spasms intensity (p = 0.091). Eleven patients were treated with both BTI and nabiximols, and only four patients continued both treatments. All dropouts were due to inefficacy of at least one of the two therapies. CONCLUSIONS Our single-centre experience highlights that both BTI and nabiximols are effective in treating multiple sclerosis-related spasticity; however, BTI treatment may be more effective on spasms intensity. Combined nabiximols and BTI treatment could represent a therapeutic option for severe spasticity.
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Affiliation(s)
- Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Alessandro Dinoto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Lara Stragapede
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Giulia Mazzon
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Maria Elisa Morelli
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Fulvio Pasquin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Alessio Bratina
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Antonio Bosco
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
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Hugos CL, Cameron MH. MS Spasticity: Take Control (STC) for ambulatory adults: protocol for a randomized controlled trial. BMC Neurol 2020; 20:368. [PMID: 33028236 PMCID: PMC7541326 DOI: 10.1186/s12883-020-01902-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Spasticity affects 60–80% of people with multiple sclerosis (MS), impacting activity, participation and quality of life. We developed the group delivered spasticity self-management program, “MS Spasticity: Take Control” (STC), with DVDs for education and lower extremity stretching. STC is based on an international guideline and recommendations from systematic reviews and emphasizes the importance of stretching with specific stretching exercises. Our pilot trial (n = 38) compared STC followed by one month of home stretching practice to unguided use of the National MS Society (NMSS) brochure titled “Stretching for People with MS: An Illustrated Manual,” also followed by one month of home stretching practice. In this pilot trial, STC showed promising effects on the impact of spasticity (MS Spasticity Scale-88) and other self-report and physical performance measures. We will now carry out a fully-powered trial to evaluate the effect of STC compared to a comparably delivered control program on the impact and severity of spasticity in people with MS and self-reported lower extremity spasticity. Methods Two hundred-twenty ambulatory adults with MS self-reported spasticity interfering with daily activities will be randomized 1:1 to STC or control, using the same NMSS brochure used in the pilot study, with both programs delivered in groups with trained facilitators. Outcomes are the impact of spasticity with the MS Spasticity Scale-88, the severity of spasticity with the Numeric Rating Scale for Spasticity, other self-report questionnaires, and physical performance walking measures at baseline and one and 6 months after the interventions. Discussion Stretching is the cornerstone of spasticity management. Stretching takes time and energy every day. Unfortunately, beyond the logical expectation that regular stretching should help prevent muscle shortening and contractures in the presence of spasticity, there is very little data on the effects of stretching on spasticity in people with MS or any other condition. Our pilot trial of STC suggested that education and stretching help reduce the impact of spasticity. To definitively determine if this education and instructional program with daily stretching practice is effective, a fully powered trial with a comparable control intervention and facilitators who did not create STC is needed. Here we report the protocol for this trial. Trial registration NCT03166930 May 25, 2017.
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Affiliation(s)
- Cinda L Hugos
- VA Portland Health Care System, 3710 SW US Veterans Hospital Rd. R&D 27, Portland, OR, 97239, USA. .,Department of Neurology, Oregon Health & Science University, 3303 SW Sam Jackson Park Rd. L226, Portland, OR, 97239, USA.
| | - Michelle H Cameron
- VA Portland Health Care System, 3710 SW US Veterans Hospital Rd. R&D 27, Portland, OR, 97239, USA.,Department of Neurology, Oregon Health & Science University, 3303 SW Sam Jackson Park Rd. L226, Portland, OR, 97239, USA
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Botulinum toxin for the management of spasticity in multiple sclerosis: the Italian botulinum toxin network study. Neurol Sci 2020; 41:2781-2792. [PMID: 32281038 DOI: 10.1007/s10072-020-04392-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/01/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Botulinum toxin (BT) is an effective and safe treatment for spasticity, with limited evidence in multiple sclerosis (MS). We aim to describe the use of BT for the management of MS spasticity in the clinical practice, its combination with other anti-spastic treatments in MS and possible MS clinical correlates. METHODS This is a multicentre cross-sectional observational study including 386 MS patients, receiving BT for spasticity in 19 Italian centres (age 53.6 ± 10.9 years; female 228 (59.1%); disease duration 18.7 ± 9.2 years; baseline Expanded Disability Status Scale (EDSS) 6.5 (2.0-9.0)). RESULTS BT was used for improving mobility (n = 170), functioning in activities of daily living (n = 56), pain (n = 56), posturing-hygiene (n = 63) and daily assistance (n = 41). BT formulations were AbobotulinumtoxinA (n = 138), OnabotulinumtoxinA (n = 133) and IncobotulinumtoxinA (n = 115). After conversion to unified dose units, higher BT dose was associated with higher EDSS (Coeff = 0.591; p < 0.001), higher modified Ashworth scale (Coeff = 0.796; p < 0.001) and non-ambulatory patients (Coeff = 209.382; p = 0.006). Lower BT dose was used in younger patients (Coeff = - 1.746; p = 0.009), with relapsing-remitting MS (Coeff = - 60.371; p = 0.012). BT dose was higher in patients with previous BT injections (Coeff = 5.167; p = 0.001), and with concomitant treatments (Coeff = 43.576; p = 0.022). Three patients (0.7%) reported on post-injection temporary asthenia/weakness (n = 2) and hypophonia (n = 1). CONCLUSION BT was used for spasticity and its consequences from the early stages of MS, without significant adverse effects. MS-specific goals and injection characteristics can be used to refer MS patients to BT treatment, to decide for the strategy of BT injections and to guide the design of future clinical trials and observational studies.
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Carotenuto A, Costabile T, De Lucia M, Moccia M, Falco F, Petruzzo M, De Angelis M, Russo CV, Saccà F, Lanzillo R, Brescia Morra V. Predictors of Nabiximols (Sativex®) discontinuation over long-term follow-up: a real-life study. J Neurol 2020; 267:1737-1743. [DOI: 10.1007/s00415-020-09739-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 11/30/2022]
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Pratt M, Stevens A, Thuku M, Butler C, Skidmore B, Wieland LS, Clemons M, Kanji S, Hutton B. Benefits and harms of medical cannabis: a scoping review of systematic reviews. Syst Rev 2019; 8:320. [PMID: 31823819 PMCID: PMC6905063 DOI: 10.1186/s13643-019-1243-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/24/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There has been increased interest in the role of cannabis for treating medical conditions. The availability of different cannabis-based products can make the side effects of exposure unpredictable. We sought to conduct a scoping review of systematic reviews assessing benefits and harms of cannabis-based medicines for any condition. METHODS A protocol was followed throughout the conduct of this scoping review. A protocol-guided scoping review conduct. Searches of bibliographic databases (e.g., MEDLINE®, Embase, PsycINFO, the Cochrane Library) and gray literature were performed. Two people selected and charted data from systematic reviews. Categorizations emerged during data synthesis. The reporting of results from systematic reviews was performed at a high level appropriate for a scoping review. RESULTS After screening 1975 citations, 72 systematic reviews were included. The reviews covered many conditions, the most common being pain management. Several reviews focused on management of pain as a symptom of conditions such as multiple sclerosis (MS), injury, and cancer. After pain, the most common symptoms treated were spasticity in MS, movement disturbances, nausea/vomiting, and mental health symptoms. An assessment of review findings lends to the understanding that, although in a small number of reviews results showed a benefit for reducing pain, the analysis approach and reporting in other reviews was sub-optimal, making it difficult to know how consistent findings are when considering pain in general. Adverse effects were reported in most reviews comparing cannabis with placebo (49/59, 83%) and in 20/24 (83%) of the reviews comparing cannabis to active drugs. Minor adverse effects (e.g., drowsiness, dizziness) were common and reported in over half of the reviews. Serious harms were not as common, but were reported in 21/59 (36%) reviews that reported on adverse effects. Overall, safety data was generally reported study-by-study, with few reviews synthesizing data. Only one review was rated as high quality, while the remaining were rated of moderate (n = 36) or low/critically low (n = 35) quality. CONCLUSIONS Results from the included reviews were mixed, with most reporting an inability to draw conclusions due to inconsistent findings and a lack of rigorous evidence. Mild harms were frequently reported, and it is possible the harms of cannabis-based medicines may outweigh benefits. SYSTEMATIC REVIEW REGISTRATION The protocol for this scoping review was posted in the Open Access (https://ruor.uottawa.ca/handle/10393/37247).
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Affiliation(s)
- Misty Pratt
- Knowledge Synthesis Group, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8 L6 Canada
| | - Adrienne Stevens
- Knowledge Synthesis Group, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8 L6 Canada
- TRIBE Graduate Program, University of Split School of Medicine, Split, Croatia
| | - Micere Thuku
- Knowledge Synthesis Group, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8 L6 Canada
| | - Claire Butler
- Knowledge Synthesis Group, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8 L6 Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3A 2B4 Canada
| | | | - L. Susan Wieland
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD USA
| | - Mark Clemons
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8 M5 Canada
- Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Salmaan Kanji
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8 M5 Canada
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Knowledge Synthesis Group, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8 L6 Canada
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8 M5 Canada
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11
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Farrell R, Baker D. An expert opinion: Optimisation of pharmacological management of multiple sclerosis related spasticity. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2019. [DOI: 10.47795/kaib7737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Spasticity is a frequent symptom in people with Multiple Sclerosis. Whilst many respond to first-line therapies it is estimated that 30-40% will have suboptimal treatment response requiring more specialised management. Such strategies include combination of oral medications, botulinum toxin, nabiximols and consideration of intrathecal therapies; baclofen or phenol. Early expert intervention as outlined in this review can have a positive impact on functional ability and quality of life for people with MS.
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The influence of physiotherapy intervention on patients with multiple sclerosis-related spasticity treated with nabiximols (THC:CBD oromucosal spray). PLoS One 2019; 14:e0219670. [PMID: 31361750 PMCID: PMC6667203 DOI: 10.1371/journal.pone.0219670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nabiximols (THC/CBD Oromucosal Spray, Sativex) is used as an add-on therapy to treat moderate to severe spasticity of Multiple Sclerosis (MS). Objectives To examine the impact of physiotherapy (PT) programs on effectiveness and persistence of nabiximols treatment in people with MS-related spasticity. Methods This is an observational multicenter study with a follow-up period of 12 weeks, conducted in routine care settings in Italy. Patients with moderate to severe MS-related spasticity who started nabiximols were included. Spasticity was evaluated by the patient-rated 0–10 numerical rating scale (NRS). Clinical data were collected at baseline (T0), 4 weeks (T1) and 12 weeks (T2) months after enrollment. Results A total of 297 MS patients were selected, 290 completed the 3 months follow-up period. Mean NRS scores were 7.6 ± 1.1 at T0, 5.8 ± 1.4 at T1 and 5.5 ± 1.5 at T2. At T1, 77% of patients reached ≥20% improvement (initial response, IR); 22% reached ≥30% improvement (clinically relevant response, CRR). At T1, patients undergoing PT had a higher probability to reach CRR (Odds Ratio = 2.6 95% CI 1.3–5.6, p = 0.01). Nabiximols was discontinued in 30/290 (10.3%) patients at T1 (early discontinuers) and in 71/290 (24.5%) patients at T2 (late discontinuers). The probability of being late discontinuers was reduced in patients undergoing PT (Hazard Ratio = 0.41; 95% CI 0.23–0.69, p = 0.001). Conclusions Our real-life study confirms nabiximols’ effectiveness in MS-related spasticity and suggests that the association of a PT program may improve overall response and persistence to nabiximols treatment.
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RABIEI Z. Phytotherapy as a Complementary Medicine for Multiple Sclerosis. Turk J Pharm Sci 2019; 16:246-251. [PMID: 32454721 PMCID: PMC7227963 DOI: 10.4274/tjps.galenos.2018.90522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022]
Abstract
Multiple sclerosis (MS) is the most common cause of neurologic disability in adults worldwide. Two main issues have caused MS patients to face several problems. One issue is that the definite cause of MS has not yet been determined and the other issue is the lack of a definite treatment for this disease. The people with MS, therefore, seek out complementary and alternative medications to manage the symptoms of this disease. Meanwhile, medicinal plants have been demonstrated to have possible positive pharmacological effects in treating MS in different models. The reliable articles indexed in the databases Web of Science, Scopus, PubMed Central, PubMed, Scientific Information Database, and Institute for Scientific Information were retrieved and analyzed to conduct this review. Medicinal plants and plant compounds caused decreases in the neurologic deficits due to MS. Clinical evidence has demonstrated the clinical potential of Cannabis sativa extract, cannabinoids, Ginkgo biloba, beta-phytosterol, and Lippia citriodora extract to improve MS symptoms. These plants and compounds can also improve spasticity, muscle spasm, neuropathic pain, and urinary tract complications in at least some of these patients. Nanocurcumins and Punica granatum L. peel extract have exhibited positive effects in animal models and can decrease neurologic deficits by reducing inflammation. Medicinal plants and their compounds can serve as new sources of MS drugs because they can improve MS symptoms.
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Affiliation(s)
- Zahra RABIEI
- Shahrekord University of Medical Sciences, Basic Health Sciences Institute, Medical Plants Research Center, Shahrekord, Iran
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14
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Akgün K, Essner U, Seydel C, Ziemssen T. Daily Practice Managing Resistant Multiple Sclerosis Spasticity With Delta-9-Tetrahydrocannabinol: Cannabidiol Oromucosal Spray: A Systematic Review of Observational Studies. J Cent Nerv Syst Dis 2019; 11:1179573519831997. [PMID: 30886530 PMCID: PMC6413425 DOI: 10.1177/1179573519831997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background/purpose: Spasticity is one of the most common symptoms in people with multiple
sclerosis (MS). Conventional anti-spasticity agents have limitations in
their efficacy and tolerability. Delta-9-tetrahydrocannabinol: cannabidiol
(THC:CBD) spray, a cannabinoid-based medicine, is approved as an add-on
therapy for MS spasticity not adequately controlled by other anti-spasticity
medications. The results from randomized controlled trials (RCTs) have
demonstrated a reduction in the severity of spasticity and associated
symptoms. However, RCTs do not always reflect real-life outcomes. We
systematically reviewed the complementary evidence from non-interventional
real-world studies. Methods: A systematic literature review was conducted to identify all non-RCT
publications on THC:CBD spray between 2011 and 2017. Data on study design,
patient characteristics, effectiveness, and safety outcomes were extracted
from those publications meeting our inclusion criteria. Results: In total, we reviewed 14 real-world publications including observational
studies and treatment registries. The proportion of patients reaching the
threshold of minimal clinical important difference (MCID), with at least a
20% reduction of the spasticity Numeric Rating Scale (NRS) score after
4 weeks ranged from 41.9% to 82.9%. The reduction in the mean NRS spasticity
score after 4 weeks was maintained over 6-12 months. The average daily dose
was five to six sprays. Delta-9-tetrahydrocannabinol: cannabidiol was well
tolerated in the evaluated studies in the same way as in the RCTs. No new or
unexpected adverse events or safety signals were reported in everyday
clinical practice. Conclusions: The data evaluated in this systematic review provide evidence for the
efficacy and safety of THC:CBD in clinical practice and confirm results
obtained in RCTs.
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Affiliation(s)
- Katja Akgün
- Department of Neurology, Center of Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
| | - Ute Essner
- O.MEANY Consultancy GmbH, Hamburg, Germany
| | | | - Tjalf Ziemssen
- Department of Neurology, Center of Clinical Neuroscience, University Hospital Dresden, Dresden, Germany
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15
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Intrathecal baclofen for multiple sclerosis related spasticity: A twenty year experience. Mult Scler Relat Disord 2019; 27:95-100. [DOI: 10.1016/j.msard.2018.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/04/2018] [Accepted: 10/13/2018] [Indexed: 11/22/2022]
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16
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Abstract
BACKGROUND Chronic pain is common and significantly impacts on the lives of persons with multiple sclerosis (pwMS). Various types of non-pharmacological interventions are widely used, both in hospital and ambulatory/mobility settings to improve pain control in pwMS, but the effectiveness and safety of many non-pharmacological modalities is still unknown. OBJECTIVES This review aimed to investigate the effectiveness and safety of non-pharmacological therapies for the management of chronic pain in pwMS. Specific questions to be addressed by this review include the following.Are non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) effective in reducing chronic pain in pwMS?What type of non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) are effective (least and most effective) and in what setting, in reducing chronic pain in pwMS? SEARCH METHODS A literature search was performed using the specialised register of the Cochrane MS and Rare Diseases of the Central Nervous System Review Group, using the Cochrane MS Group Trials Register which contains CENTRAL, MEDLINE, Embase, CINAHL, LILACUS, Clinical trials.gov and the World Health Organization International Clinical Trials Registry Platform on 10 December 2017. Handsearching of relevant journals and screening of reference lists of relevant studies was carried out. SELECTION CRITERIA All published randomised controlled trials (RCTs)and cross-over studies that compared non-pharmacological therapies with a control intervention for managing chronic pain in pwMS were included. Clinical controlled trials (CCTs) were eligible for inclusion. DATA COLLECTION AND ANALYSIS All three review authors independently selected studies, extracted data and assessed the methodological quality of the studies using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool for best-evidence synthesis. Pooling data for meta-analysis was not possible due to methodological, clinical and statistically heterogeneity of the included studies. MAIN RESULTS Overall, 10 RCTs with 565 participants which investigated different non-pharmacological interventions for the management of chronic pain in MS fulfilled the review inclusion criteria. The non-pharmacological interventions evaluated included: transcutaneous electrical nerve stimulation (TENS), psychotherapy (telephone self-management, hypnosis and electroencephalogram (EEG) biofeedback), transcranial random noise stimulation (tRNS), transcranial direct stimulation (tDCS), hydrotherapy (Ai Chi) and reflexology.There is very low-level evidence for the use of non-pharmacological interventions for chronic pain such as TENS, Ai Chi, tDCS, tRNS, telephone-delivered self-management program, EEG biofeedback and reflexology in pain intensity in pwMS. Although there were improved changes in pain scores and secondary outcomes (such as fatigue, psychological symptoms, spasm in some interventions), these were limited by methodological biases within the studies. AUTHORS' CONCLUSIONS Despite the use of a wide range of non-pharmacological interventions for the treatment of chronic pain in pwMS, the evidence for these interventions is still limited or insufficient, or both. More studies with robust methodology and greater numbers of participants are needed to justify the effect of these interventions for the management of chronic pain in pwMS.
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Affiliation(s)
- Bhasker Amatya
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
| | - Jamie Young
- Melbourne HealthRehabilitation MedicineRoyal Melbourne Hospital Royal Park Campus34‐54 Poplar Road, ParkvilleMelbourneVictoriaAustralia3011
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
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17
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Traditional Uses of Cannabinoids and New Perspectives in the Treatment of Multiple Sclerosis. MEDICINES 2018; 5:medicines5030091. [PMID: 30111755 PMCID: PMC6164967 DOI: 10.3390/medicines5030091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 12/24/2022]
Abstract
Recent findings highlight the emerging role of the endocannabinoid system in the control of symptoms and disease progression in multiple sclerosis (MS). MS is a chronic, immune-mediated, demyelinating disorder of the central nervous system with no cure so far. It is widely reported in the literature that cannabinoids might be used to control MS symptoms and that they also might exert neuroprotective effects and slow down disease progression. This review aims to give an overview of the principal cannabinoids (synthetic and endogenous) used for the symptomatic amelioration of MS and their beneficial outcomes, providing new potentially possible perspectives for the treatment of this disease.
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18
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Nielsen S, Germanos R, Weier M, Pollard J, Degenhardt L, Hall W, Buckley N, Farrell M. The Use of Cannabis and Cannabinoids in Treating Symptoms of Multiple Sclerosis: a Systematic Review of Reviews. Curr Neurol Neurosci Rep 2018; 18:8. [PMID: 29442178 DOI: 10.1007/s11910-018-0814-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Pharmaceutical cannabinoids such as nabiximols, nabilone and dronabinol, and plant-based cannabinoids have been investigated for their therapeutic potential in treating multiple sclerosis (MS) symptoms. This review of reviews aimed to synthesise findings from high quality systematic reviews that examined the safety and effectiveness of cannabinoids in multiple sclerosis. We examined the outcomes of disability and disability progression, pain, spasticity, bladder function, tremor/ataxia, quality of life and adverse effects. RECENT FINDINGS We identified 11 eligible systematic reviews providing data from 32 studies, including 10 moderate to high quality RCTs. Five reviews concluded that there was sufficient evidence that cannabinoids may be effective for symptoms of pain and/or spasticity in MS. Few reviews reported conclusions for other symptoms. Recent high quality reviews find cannabinoids may have modest effects in MS for pain or spasticity. Future research should include studies with non-cannabinoid comparators; this is an important gap in the evidence.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, 2052, Australia.
| | - Rada Germanos
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, 2052, Australia
| | - Megan Weier
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, 2052, Australia.,Centre for Youth Substance Abuse Research, The University of Queensland, Royal Brisbane and Women's Hospital Brisbane, Brisbane, QLD, 4006, Australia
| | - John Pollard
- School of Medical Sciences, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, 2052, Australia
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, The University of Queensland, Royal Brisbane and Women's Hospital Brisbane, Brisbane, QLD, 4006, Australia
| | - Nicholas Buckley
- School of Medical Sciences, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, 2052, Australia
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19
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Cascaes LHFDS, Oliveira JCD. Evidências sobre relaxantes musculares de uso ambulatorial: uma revisão da literatura. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2018. [DOI: 10.5712/rbmfc12(39)1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objetivo: Avaliar as evidências sobre eficácia e efeitos adversos dos relaxantes musculares de uso oral disponíveis no Brasil para espasticidade, condições musculoesqueléticas, fibromialgia e cefaleia tensional. Métodos: Realizou-se uma revisão da literatura a partir de revisões sistemáticas publicadas no Medline, BVS, biblioteca Cochrane e National Institute for Health and Care Excellence (NICE) até dezembro de 2016, que avaliaram os fármacos considerados relaxantes musculares pela Anatomical Therapeutic Chemical (ATC) e disponíveis no Brasil na forma oral: ciclobenzaprina, tizanidina, carisoprodol, orfenadrina e baclofeno. Resultados: Foram identificados 20 estudos, sendo 17 revisões sistemáticas e três meta-análises. As evidências de eficácia dos relaxantes musculares consistem principalmente em estudos com concepção metodológica ruim. Estudos de comparação não mostraram que um relaxante muscular esquelético seja superior a outro. Ciclobenzaprina demonstrou eficácia em condições musculoesqueléticas, como dor miofascial mandibular, fibromialgia e dor lombar. Na fibromialgia, demonstrou benefício na melhora geral e no sono. No manejo da dor lombar, a ciclobenzaprina mostrou efeito modesto, mais presente nos quatro primeiros dias. Carisoprodol na dor lombar baixa não parece ter diferença de ciclobenzaprina, mas esse medicamento pode causar dependência. Baclofeno e tizanidina parecem ser eficazes em comparação com placebo e equivalentes em doentes com espasticidade. Conclusões: Os relaxantes musculares em geral, comparados a placebo ou entre si, apresentaram poucas evidências com estatística significante. Portanto, a seleção do medicamento deve ser baseada no perfil de efeitos adversos, preferência do paciente, potencial de abuso, potencial de interação com outros medicamentos, custo e outras características dos fármacos.
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20
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Synnot A, Chau M, Pitt V, O'Connor D, Gruen RL, Wasiak J, Clavisi O, Pattuwage L, Phillips K. Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev 2017; 11:CD008929. [PMID: 29165784 PMCID: PMC6486165 DOI: 10.1002/14651858.cd008929.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI. OBJECTIVES To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI. SEARCH METHODS In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data. MAIN RESULTS We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes. AUTHORS' CONCLUSIONS The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.
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Affiliation(s)
- Anneliese Synnot
- Monash UniversityCochrane Australia, School of Public Health and Preventive MedicineL4 551 St Kilda RdMelbourneVictoriaAustralia3004
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Marisa Chau
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Veronica Pitt
- Australian & New Zealand Intensive Care Research Centre (ANZIC‐RC), Monash UniversityLevel 6, The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Denise O'Connor
- Monash UniversitySchool of Public Health and Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Jason Wasiak
- University of MelbourneMelbourne School of Health SciencesGrattan Street, ParkvilleMelbourneVictoriaAustralia
| | - Ornella Clavisi
- MOVE muscle, bone & joint health263‐265 Kooyong Rd ElsternwickMelbourneVICAustralia3185
| | - Loyal Pattuwage
- Centre for Evidence and ImplementationEast MelbourneVICAustralia3175
| | - Kate Phillips
- Monash UniversitySchool of Public Health & Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
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21
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Latino P, Castelli L, Prosperini L, Marchetti MR, Pozzilli C, Giovannelli M. Determinants of botulinum toxin discontinuation in multiple sclerosis: a retrospective study. Neurol Sci 2017; 38:1841-1848. [PMID: 28766025 DOI: 10.1007/s10072-017-3078-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/19/2017] [Indexed: 10/19/2022]
Abstract
The purpose of the present study was to investigate the long-term persistence to treatment with botulinum toxin type A (BoNT-A) for multiple sclerosis (MS)-related spasticity and the determinants of BoNT-A discontinuation in daily clinical setting. We retrospectively collected data of patients who started BoNT-A injections and underwent regular follow-up visits. Determinants of BoNT-A discontinuation were explored in a time-to-event Cox regression analysis which included as independent variables a large set of demographic and clinical characteristics. A total of 185 patients started BoNT-A injections from 2002 to 2014 and were followed up to September 2016. Of them, data on 121 were considered in our analysis. At follow-up, 53 (44%) patients were still on treatment and 68 (56%) patients discontinued BoNT-A after a median time of 1.2 years [interval 6 months to 7.4 years]. The reasons for discontinuation were loss of efficacy (n = 45), logistic problems or barriers to reach the structure (n = 16), and adverse events (n = 7). The absence of caregiver (hazard ratio = 1.69, p = 0.03) and lack of regular rehabilitation (hazard ratio = 1.78, p = 0.02) were two independent predictors for BoNT-A discontinuation. Our study confirms the beneficial effect of combining BoNT-A injections with rehabilitation and highlights the crucial role of caregivers for achieving better long-term outcomes in people with MS suffering from spasticity.
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Affiliation(s)
- Pamela Latino
- S. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Letizia Castelli
- S. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Luca Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Viale dell'Università 30, 00185, Rome, Italy.
| | - Maria Rita Marchetti
- S. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Carlo Pozzilli
- S. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189, Rome, Italy.,Department of Neurology and Psychiatry, Sapienza University, Viale dell'Università 30, 00185, Rome, Italy
| | - Morena Giovannelli
- S. Andrea Hospital, Sapienza University, Via di Grottarossa 1035, 00189, Rome, Italy
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22
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Messina S, Solaro C, Righini I, Bergamaschi R, Bonavita S, Bossio RB, Brescia Morra V, Costantino G, Cavalla P, Centonze D, Comi G, Cottone S, Danni MC, Francia A, Gajofatto A, Gasperini C, Zaffaroni M, Petrucci L, Signoriello E, Maniscalco GT, Spinicci G, Matta M, Mirabella M, Pedà G, Castelli L, Rovaris M, Sessa E, Spitaleri D, Paolicelli D, Granata A, Zappia M, Patti F. Sativex in resistant multiple sclerosis spasticity: Discontinuation study in a large population of Italian patients (SA.FE. study). PLoS One 2017; 12:e0180651. [PMID: 28763462 PMCID: PMC5538735 DOI: 10.1371/journal.pone.0180651] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The approval of Sativex for the management of multiple sclerosis (MS) spasticity opened a new opportunity to many patients. In Italy, the healthcare payer can be fully reimbursed by the involved pharma company with the cost of treatment for patients not responding after a 4 week (28 days) trial period (Payment by Results, PbR), and 50% reimbursed with the cost of 6 weeks (42 days) treatment for other patients discontinuing (Cost Sharing, CS). The aim of our study was to describe the Sativex discontinuation profile from a large population of spasticity treated Italian MS patients. METHODS We collected data of patients from 30 MS centres across the country starting Sativex between January 2014 and February 2015. Data were collected from the mandatory Italian Medicines Agency (AIFA) web-registry. Predictors of treatment discontinuation were assessed using a multivariate Cox proportional regression analysis. RESULTS During the observation period 631 out of 1597 (39.5%) patients discontinued Sativex. The Kaplan-Meier estimates curve showed that 333 patients (20.8%) discontinued treatment at 4 weeks while 422 patients (26.4%) discontinued at 6 weeks. We found after adjusted modeling that a higher NRS score at T1 (adjHR 2.23, 95% 2.07-2.41, p<0.001) and a lower baseline NRS score (adjHR 0.51 95% CI 0.46-0.56, p<0.001) were predictive of treatment discontinuation. CONCLUSION These data show that the first 6 weeks are useful in identifying those patients in which Sativex could be effective, thus avoiding the cost of longer term evaluation.
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Affiliation(s)
- Silvia Messina
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
| | - Claudio Solaro
- Neurology Unit, Department Head And Neck, ASL3 Genova, Italy
| | | | | | | | - Roberto Bruno Bossio
- Neurology Operating Unit and Multiple Sclerosis Center—Provincial Health Authority of Cosenza, Cosenza, Italy
| | | | | | - Paola Cavalla
- A.O.U: Cittàdella Salute e dellaScienza di Torino, Torino, Italy
| | - Diego Centonze
- Neuroscience Department—University Tor Vegata, Rome, Italy
- Unit of Neurology and of Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Giancarlo Comi
- Department of Neurology–San Raffaele Hospital, Milan, Italy
| | | | | | - Ada Francia
- Multiple Sclerosis Center, Dept. Neurol. Psich—Sapienza University, Rome, Italy
| | - Alberto Gajofatto
- Department of Neuroscience, Biomedicine and Movement Multiple Sclerosis Centre–University of Verona, Verona, Italy
| | | | - Mauro Zaffaroni
- Multiple Sclerosis Centre—Sant'Antonio Abate Hospital, Gallarate, Italy
| | | | | | | | | | - Manuela Matta
- Multiple Sclerosis Centre (CRESM)—San Luigi Gonzaga Hospital, Orbassano, Italy
| | | | | | | | - Marco Rovaris
- Multiple Sclerosis Centre—IRCCS Don Gnocchi Foundation, Milan, Italy
| | - Edoardo Sessa
- Multiple Sclerosis Centre—IRCCS-Bonino Pulejo Centre, Messina, Italy
| | | | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs—University of Bari “Aldo Moro” Bari, Italy
| | - Alfredo Granata
- Department of Medical Sciences, Institute of Neurology—University “Magna Graecia”, Catanzaro, Italy
| | - Mario Zappia
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
| | - Francesco Patti
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia"–University of Catania, Catania, Italy
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23
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Baker D, Pryce G, Visintin C, Sisay S, Bondarenko AI, Vanessa Ho WS, Jackson SJ, Williams TE, Al-Izki S, Sevastou I, Okuyama M, Graier WF, Stevenson LA, Tanner C, Ross R, Pertwee RG, Henstridge CM, Irving AJ, Schulman J, Powell K, Baker MD, Giovannoni G, Selwood DL. Big conductance calcium-activated potassium channel openers control spasticity without sedation. Br J Pharmacol 2017; 174:2662-2681. [PMID: 28677901 PMCID: PMC5522996 DOI: 10.1111/bph.13889] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/27/2017] [Accepted: 05/17/2017] [Indexed: 12/19/2022] Open
Abstract
Background and Purpose Our initial aim was to generate cannabinoid agents that control spasticity, occurring as a consequence of multiple sclerosis (MS), whilst avoiding the sedative side effects associated with cannabis. VSN16R was synthesized as an anandamide (endocannabinoid) analogue in an anti‐metabolite approach to identify drugs that target spasticity. Experimental Approach Following the initial chemistry, a variety of biochemical, pharmacological and electrophysiological approaches, using isolated cells, tissue‐based assays and in vivo animal models, were used to demonstrate the activity, efficacy, pharmacokinetics and mechanism of action of VSN16R. Toxicological and safety studies were performed in animals and humans. Key Results VSN16R had nanomolar activity in tissue‐based, functional assays and dose‐dependently inhibited spasticity in a mouse experimental encephalomyelitis model of MS. This effect occurred with over 1000‐fold therapeutic window, without affecting normal muscle tone. Efficacy was achieved at plasma levels that are feasible and safe in humans. VSN16R did not bind to known CB1/CB2/GPPR55 cannabinoid‐related receptors in receptor‐based assays but acted on a vascular cannabinoid target. This was identified as the major neuronal form of the big conductance, calcium‐activated potassium (BKCa) channel. Drug‐induced opening of neuronal BKCa channels induced membrane hyperpolarization, limiting excessive neural‐excitability and controlling spasticity. Conclusions and Implications We identified the neuronal form of the BKCa channel as the target for VSN16R and demonstrated that its activation alleviates neuronal excitability and spasticity in an experimental model of MS, revealing a novel mechanism to control spasticity. VSN16R is a potential, safe and selective ligand for controlling neural hyper‐excitability in spasticity.
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Affiliation(s)
- David Baker
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Gareth Pryce
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - Cristina Visintin
- Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK.,Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Sofia Sisay
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alexander I Bondarenko
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Graz, Austria.,A.A. Bogomoletz Institute of Physiology, Kiev, Ukraine
| | - W S Vanessa Ho
- Vascular Biology Research Centre. St. George's, University of London, London, UK
| | - Samuel J Jackson
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Thomas E Williams
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sarah Al-Izki
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ioanna Sevastou
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Masahiro Okuyama
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
| | - Wolfgang F Graier
- Institute of Molecular Biology and Biochemistry, Medical University of Graz, Graz, Austria
| | - Lesley A Stevenson
- Vascular Biology Research Centre. St. George's, University of London, London, UK
| | - Carolyn Tanner
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Ruth Ross
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Roger G Pertwee
- Department of Biomedical Sciences, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Christopher M Henstridge
- Neurosciences Institute, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Andrew J Irving
- Neurosciences Institute, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Jesse Schulman
- Canbex Therapeutics Ltd, London BioScience Innovation Centre, London, UK
| | - Keith Powell
- Canbex Therapeutics Ltd, London BioScience Innovation Centre, London, UK
| | - Mark D Baker
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gavin Giovannoni
- Neuroimmunology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
| | - David L Selwood
- Department of Medicinal Chemistry, UCL Wolfson Institute for Biomedical Research, University College London, London, UK
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24
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Luo D, Wu G, Ji Y, Zhang Z, He F, Mou X, Zhu Q, Yang B. The comparative study of clinical efficacy and safety of baclofen vs tolperisone in spasticity caused by spinal cord injury. Saudi Pharm J 2017; 25:655-659. [PMID: 28579907 PMCID: PMC5447437 DOI: 10.1016/j.jsps.2017.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
In the present study we compared the clinical efficacy and safety of baclofen vs tolperisone in spasticity caused by spinal cord injury. A total of 150 patients were enrolled in the present study and were divided into two groups with 75 patients in each group, receiving baclofen or tolperisone, respectively. We used Modified Ashworth Scale, Medical research council scale, Barthel Index, and Coefficient of efficacy to measure clinical efficacy. After 6-week treatment, both groups demonstrated significant improvement in muscle tone, muscle strength and functional outcome (Group I, 1.55 ± 0.053, 2.79 ± 0.032, 59.31 ± 1.32; Group II, 1.57 ± 0.053, 3.04 ± 0.032, 73 ± 1.32 respectively). There was no significant difference regarding improvement in muscle tone and muscle strength between the two groups (Group I, 1.055 ± 0.053 vs Group II, 1.57 ± 0.053; Group I, 2.79 ± 0.032 vs Group II, 3.04 ± 0.032, p > 0.05). However, the improvement in functional outcomes was greater in group II as compared to that in group I (Group I, 59.31 ± 1.32 vs Group II, 73 ± 1.32, p < 0.05). In addition, overall efficacy coefficient was greater for group II as compared to group I (Group I, 3.6 vs Group II, 2.3, p < 0.05). Group I had more side effects compared to Group II. Compared to baclofen, tolperisone offers greater improvement in activities of daily living compared to baclofen.
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Affiliation(s)
- Dejun Luo
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Guoyong Wu
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Yong Ji
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Zhaoyao Zhang
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Fayou He
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Xiaping Mou
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Qingmao Zhu
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
| | - Bo Yang
- Department of Orthopedics, Jianyang People's Hospital of Sichuan, Jianyang 641400, China
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25
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Naro A, Leo A, Russo M, Casella C, Buda A, Crespantini A, Porcari B, Carioti L, Billeri L, Bramanti A, Bramanti P, Calabrò RS. Breakthroughs in the spasticity management: Are non-pharmacological treatments the future? J Clin Neurosci 2017; 39:16-27. [DOI: 10.1016/j.jocn.2017.02.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/12/2017] [Indexed: 12/16/2022]
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26
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Amatya B, Young J, Khan F. Non-pharmacological interventions for chronic pain in multiple sclerosis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Bhasker Amatya
- Royal Melbourne Hospital, Royal Park Campus; Department of Rehabilitation Medicine; Poplar Road Parkville Melbourne Victoria Australia 3052
| | - Jamie Young
- Melbourne Health; Rehabilitation Medicine; Royal Melbourne Hospital Royal Park Campus 34-54 Poplar Road, Parkville Melbourne Victoria Australia 3011
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park Campus; Department of Rehabilitation Medicine; Poplar Road Parkville Melbourne Victoria Australia 3052
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27
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Backus D, Manella C, Bender A, Sweatman M. Impact of Massage Therapy on Fatigue, Pain, and Spasticity in People with Multiple Sclerosis: a Pilot Study. Int J Ther Massage Bodywork 2016; 9:4-13. [PMID: 27974947 PMCID: PMC5142712 DOI: 10.3822/ijtmb.v9i4.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic, immune-mediated, inflammatory disease that leads to fatigue, pain, and spasticity, as well as other sensorimotor and cognitive changes. Often traditional medical approaches are ineffective in alleviating these disruptive symptoms. Although about one-third of surveyed individuals report they use massage therapy (MT) as an adjunct to medical treatment, there is little empirical evidence that MT is effective for symptom management in people with MS. PURPOSE To measure the effects of MT on fatigue, pain, spasticity, perception of health, and quality of life in people with MS. SETTING Not-for-profit long-term care facility. PARTICIPANTS Twenty-four of 28 enrolled individuals with MS (average age = 47.38, SD = 13.05; 22 female) completed all MT sessions and outcome assessments. RESEARCH DESIGN Nonrandomized, pre-post pilot study. INTERVENTION Standardized MT routine one time a week for six weeks. MAIN OUTCOME MEASURES Modified Fatigue Index Scale (MFIS), MOS Pain Effects Scale (MOS Pain), and Modified Ashworth Scale (MAS). Secondary outcome measures: Mental Health Inventory (MHI) and Health Status Questionnaire (HSQ). RESULTS There was a significant improvement in MFIS (p < .01), MOS Pain (p < .01), MHI (p < .01), and HSQ (p < .01), all with a large effect size (ES) (Cohen's d = -0.76, 1.25, 0.93, -1.01, respectively). There was a significant correlation between change scores on the MFIS and the MOS Pain (r = 0.532, p < .01), MHI (r = -0.647, p < .01), and subscales of the HSQ (ranging from r = -0.519, to -0.619, p < .01). CONCLUSIONS MT as delivered in this study is a safe and beneficial intervention for management of fatigue and pain in people with MS. Decreasing fatigue and pain appears to correlate with improvement in quality of life, which is meaningful for people with MS who have a chronic disease resulting in long-term health care needs.
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28
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Botulinum toxin therapy for treatment of spasticity in multiple sclerosis: review and recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders task force. J Neurol 2016; 264:112-120. [PMID: 27787630 DOI: 10.1007/s00415-016-8304-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
Abstract
Botulinum toxin (BT) therapy is an established treatment of spasticity due to stroke. For multiple sclerosis (MS) spasticity this is not the case. IAB-Interdisciplinary Working Group for Movement Disorders formed a task force to explore the use of BT therapy for treatment of MS spasticity. A formalised PubMed literature search produced 55 publications (3 randomised controlled trials, 3 interventional studies, 11 observational studies, 2 case studies, 35 reviews, 1 guideline) all unanimously favouring the use of BT therapy for MS spasticity. There is no reason to believe that BT should be less effective and safe in MS spasticity than it is in stroke spasticity. Recommendations include an update of the current prevalence of MS spasticity and its clinical features according to classifications used in movement disorders. Immunological data on MS patients already treated should be analysed with respect to frequencies of MS relapses and BT antibody formation. Registration authorities should expand registration of BT therapy for spasticity regardless of its aetiology. MS specialists should consider BT therapy for symptomatic treatment of spasticity.
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29
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Patti F, Messina S, Solaro C, Amato MP, Bergamaschi R, Bonavita S, Bruno Bossio R, Brescia Morra V, Costantino GF, Cavalla P, Centonze D, Comi G, Cottone S, Danni M, Francia A, Gajofatto A, Gasperini C, Ghezzi A, Iudice A, Lus G, Maniscalco GT, Marrosu MG, Matta M, Mirabella M, Montanari E, Pozzilli C, Rovaris M, Sessa E, Spitaleri D, Trojano M, Valentino P, Zappia M. Efficacy and safety of cannabinoid oromucosal spray for multiple sclerosis spasticity. J Neurol Neurosurg Psychiatry 2016; 87:944-51. [PMID: 27160523 PMCID: PMC5013116 DOI: 10.1136/jnnp-2015-312591] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The approval of 9-δ-tetrahydocannabinol and cannabidiol (THC:CBD) oromucosal spray (Sativex) for the management of treatment-resistant multiple sclerosis (MS) spasticity opened a new opportunity for many patients. The aim of our study was to describe Sativex effectiveness and adverse events profile in a large population of Italian patients with MS in the daily practice setting. METHODS We collected data of all patients starting Sativex between January 2014 and February 2015 from the mandatory Italian medicines agency (AIFA) e-registry. Spasticity assessment by the 0-10 numerical rating scale (NRS) scale is available at baseline, after 1 month of treatment (trial period), and at 3 and 6 months. RESULTS A total of 1615 patients were recruited from 30 MS centres across Italy. After one treatment month (trial period), we found 70.5% of patients reaching a ≥20% improvement (initial response, IR) and 28.2% who had already reached a ≥30% improvement (clinically relevant response, CRR), with a mean NRS score reduction of 22.6% (from 7.5 to 5.8). After a multivariate analysis, we found an increased probability to reach IR at the first month among patients with primary and secondary progressive MS, (n=1169, OR 1.4 95% CI 1.04 to 1.9, p=0.025) and among patients with >8 NRS score at baseline (OR 1.8 95% CI 1.3-2.4 p<0.001). During the 6 months observation period, 631(39.5%) patients discontinued treatment. The main reasons for discontinuation were lack of effectiveness (n=375, 26.2%) and/or adverse events (n=268, 18.7%). CONCLUSIONS Sativex can be a useful and safe option for patients with MS with moderate to severe spasticity resistant to common antispastic drugs.
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Affiliation(s)
- F Patti
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
| | - S Messina
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
| | - C Solaro
- Neurology Unit, Department Head and Neck, ASL3 Genova, Genova, Italy
| | - M P Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - R Bergamaschi
- Department of Neurology, Neurology Institute C Mondino, Pavia, Italy
| | - S Bonavita
- I Clinic Neurology, II University of Naples, Naples, Italy
| | - R Bruno Bossio
- Neurology Operating Unit, Multiple Sclerosis Center, Provincial Health Authority of Cosenza, Cosenza, Italy
| | - V Brescia Morra
- Multiple Sclerosis Centre, University Federico II, Naples, Italy
| | - G F Costantino
- Demyelinating Diseases Centre, Foggia Hospital, Foggia, Italy
| | - P Cavalla
- Multiple Sclerosis Centre, S. Giovanni Battista, Molinette Hospital, Turin, Italy
| | - D Centonze
- Department of Systems Medicine, Multiple Sclerosis Clinical and Research Center, Tor Vergata University, Rome, Italy Unit of Neurology and of Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - G Comi
- Department of Neurology, San Raffaele Hospital, Milan, Italy
| | - S Cottone
- Neuroimmunology Unit, Villa Sofia-Cervello Hospital, Palermo, Italy
| | - M Danni
- Neurology Clinic, Ancona Hospital, Ancona, Italy
| | - A Francia
- Department Neurol Psich, Multiple Sclerosis Center, Sapienza University, Rome, Italy
| | - A Gajofatto
- Multiple Sclerosis Centre, University of Verona, Verona, Italy
| | - C Gasperini
- Neurology Division, San Camillo Hospital, Rome, Italy
| | - A Ghezzi
- Multiple Sclerosis Centre, Sant'Antonio Abate Hospital, Gallarate, Italy
| | - A Iudice
- Multiple Sclerosis Centre, University Hospital Pisa, Pisa, Italy
| | - G Lus
- Multiple Sclerosis Center, Second University of Naples, Naples, Italy
| | - G T Maniscalco
- Multiple Sclerosis Centre, Cardarelli Hospital, Naples, Italy
| | - M G Marrosu
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - M Matta
- Multiple Sclerosis Centre (CRESM), San Luigi Gonzaga Hospital, Orbassano, Italy
| | - M Mirabella
- Multiple Sclerosis Centre, Cattolica University, Rome, Italy
| | - E Montanari
- Multiple Sclerosis Centre, Vaio Hospital, Fidenza, Italy
| | - C Pozzilli
- Multiple Sclerosis Centre, S. Andrea Hospital, Rome, Italy
| | - M Rovaris
- Multiple Sclerosis Centre, IRCCS Don Gnocchi Foundation, Milan, Italy
| | - E Sessa
- Multiple Sclerosis Centre, IRCCS-Bonino Pulejo Centre, Messina, Italy
| | - D Spitaleri
- Multiple Sclerosis Centre, San G. Moscati Hospital, Avellino, Italy
| | - M Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - P Valentino
- Department of Medical Sciences, Institute of Neurology, University "Magna Graecia", Catanzaro, Italy
| | - M Zappia
- Department of Medical, Surgical Science and Advanced Technology "GF Ingrassia", University of Catania, Catania, Italy
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30
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A Cross-Sectional Study of the Impact of Spasticity on Daily Activities in Multiple Sclerosis. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 9:537-546. [DOI: 10.1007/s40271-016-0173-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Hughes KE, Nickel D, Gurney-Dunlop T, Knox KB. Total knee arthroplasty in multiple sclerosis. Arthroplast Today 2016; 2:117-122. [PMID: 28326412 PMCID: PMC5045468 DOI: 10.1016/j.artd.2015.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 11/10/2022] Open
Abstract
We present a case report of total knee arthroplasty complicated by spasticity and contractures in a patient with multiple sclerosis (MS). Four previous case reports in the literature describe adverse outcomes after total knee arthroplasty in persons with MS secondary to severe spasticity. Preoperative, intraoperative, and postoperative considerations for persons with MS, which may help to improve functional outcomes, are discussed. Prospective research is needed among persons with MS to help determine the timing and selection of persons for arthroplasty and to minimize complications related to spasticity.
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Affiliation(s)
| | - Darren Nickel
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Tanner Gurney-Dunlop
- Division of Orthopedic Surgery, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Katherine B Knox
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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32
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Milinis K, Tennant A, Young C. Spasticity in multiple sclerosis: Associations with impairments and overall quality of life. Mult Scler Relat Disord 2016; 5:34-9. [DOI: 10.1016/j.msard.2015.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 10/06/2015] [Accepted: 10/20/2015] [Indexed: 02/04/2023]
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33
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Zettl UK, Rommer P, Hipp P, Patejdl R. Evidence for the efficacy and effectiveness of THC-CBD oromucosal spray in symptom management of patients with spasticity due to multiple sclerosis. Ther Adv Neurol Disord 2016; 9:9-30. [PMID: 26788128 PMCID: PMC4710104 DOI: 10.1177/1756285615612659] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spasticity, one of the main symptoms of multiple sclerosis (MS), can affect more than 80% of MS patients during the course of their disease and is often not treated adequately. δ-9-Tetrahydrocannabinol-cannabidiol (THC-CBD) oromucosal spray is a plant-derived, standardized cannabinoid-based oromucosal spray medicine for add-on treatment of moderate to severe, resistant multiple sclerosis-induced spasticity. This article reviews the current evidence for the efficacy and safety, with dizziness and fatigue as the most common treatment-related adverse events, being mostly mild to moderate in severity. Results from both randomized controlled phase III studies involving about,1600 MS patients or 1500 patient-years and recently published studies on everyday clinical practice involving more than 1000 patients or more than,1000 patient-years are presented.
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Affiliation(s)
- Uwe K. Zettl
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Paulus Rommer
- Department of Neurology, University of Rostock, Germany
- Department of Neurology, Medical University of Vienna, Austria
| | | | - Robert Patejdl
- Department of Neurology, University of Rostock, Germany Oscar-Langendorff-Institute of Physiology, University of Rostock, Germany
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34
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Korzhova JE, Chervyakov AV, Poydasheva AG, Kochergin IA, Peresedova AV, Zakharova MN, Suponeva NA, Chernikova LA, Piradov MA. [The application of high-frequency and iTBS transcranial magnetic stimulation for the treatment of spasticity in the patients presenting with secondary progressive multiple sclerosis]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2016; 93:8-13. [PMID: 27801405 DOI: 10.17116/kurort201658-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
UNLABELLED Spasticity is considered to be a common manifestation of multiple sclerosis. Muscle relaxants are not sufficiently effective; more than that, some of them often cause a variety of adverse reactions. Transcranial magnetic stimulation (TMS) can be a promising new tool for the treatment of spasticity. The objective of the present study was to compare the effectiveness of the two TMS protocols: rhythmic (high-frequency) TMS (rTMS) and stimulation with the theta bursts (iTBS) in terms of their ability to reduce spasticity in the patients presenting with multiple sclerosis. PATIENTS AND METHODS Twenty two patients with secondary-progressive multiple sclerosis were pseudo-randomized into two groups: those in the first (high-frequency) group received the treatment with the use of rTMS therapy at a frequency of 10 Hz; the patients of the second group, underwent stimulation with the theta bursts (iTBS). All the patients received 10 sessions of either stimulation applied to the primary motor area (M1) of both legs. The effectiveness of TMS protocols was evaluated before therapy and after 10 sessions of stimulation based on the Modified Ashworth scale (MAS), the expanded disability status scale (EDSS), and the Kurtzke functional scale (Kfs). In addition, the patients were interviewed before treatment, after 10 rTMS sessions, immediately after and within 2 and 12 weeks after the completion of the treatment using questionnaires for the evaluation of spasticity (SESS) , fatigue, and dysfunction of the pelvic organs (severity of defecation and urination disorders), fatigue. RESULTS The study has demonstrated a significant reduction in spasticity in the patients of both groups at the end of the TMS protocol based on the MAS scale. There was no significant difference between the outcomes of the two protocols. Both had positive effect on the concomitant «non-motor» symptoms (fatigue, dysfunction of the pelvic organs). CONCLUSION High-frequency transcranial magnetic stimulation (10 sessions of rTMS therapy at a frequency of 10 Hz) and stimulation with the theta-bursts applied to the M1 area in both legs can be an effective alternative treatment of spasticity in the patients with secondary-progressive multiple sclerosis. Further research is needed to detect more accurately the differences between the outcomes of the two stimulation protocols and the development of indications for their application on an individual basis.
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Affiliation(s)
- J E Korzhova
- Russian Research Center of Neurology, Moscow, Russia
| | | | | | - I A Kochergin
- Russian Research Center of Neurology, Moscow, Russia
| | | | - M N Zakharova
- Russian Research Center of Neurology, Moscow, Russia
| | - N A Suponeva
- Russian Research Center of Neurology, Moscow, Russia
| | | | - M A Piradov
- Russian Research Center of Neurology, Moscow, Russia
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Ferrè L, Nuara A, Pavan G, Radaelli M, Moiola L, Rodegher M, Colombo B, Keller Sarmiento IJ, Martinelli V, Leocani L, Martinelli Boneschi F, Comi G, Esposito F. Efficacy and safety of nabiximols (Sativex(®)) on multiple sclerosis spasticity in a real-life Italian monocentric study. Neurol Sci 2015; 37:235-42. [PMID: 26474875 DOI: 10.1007/s10072-015-2392-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/01/2015] [Indexed: 11/30/2022]
Abstract
Multiple sclerosis (MS) patients frequently suffer from limb spasticity and pain despite antispastic treatments. To investigate nabiximols efficacy and safety in a real-world monocentric Italian cohort, the following data were collected at baseline, week 4, 14 and 48: Ambulation Index (AI), 10-min walking test (10MWT), combined Modified Ashworth scale (cMAS), scores at numerical rating scale for spasticity (sNRS) and pain (pNRS). Responder status was defined as a ≥20 % reduction in sNRS after 4 weeks of treatment. 144 MS patients (123 progressive and 21 relapsing-remitting) complaining of moderate-to-severe spasticity (mean sNRS: 7.5) were included: 138 (95.8 %) completed the first month of therapy and were classified as follows-23.2 % were non-responders, 5.1 % were responders but discontinued treatment due to side effects, 71.7 % were responders with a mean 32 % reduction in sNRS (p < 0.001). In responders sNRS further decreased between 4 and 14 weeks (p = 0.03). Similarly, pNRS improvement was seen during the first month and between 4 and 14 weeks (p < 0.001 and p = 0.004, respectively). Moreover, at 4 weeks responders showed a significant (p < 0.05) improvement in cMAS, AI and 10MWT, which was maintained at 14 weeks. At 1-year follow-up, a benefit was still evident on spasticity and painful symptoms with a low drop-out rate. Confusion/ideomotor slowing, fatigue and dizziness were the most frequent side effects; no major adverse events were reported. Shorter disease duration at treatment start was associated with better response. This real-world study confirms nabiximols efficacy and safety in the treatment of MS-related spasticity and pain, which is maintained up to 48 weeks.
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Affiliation(s)
- Laura Ferrè
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Arturo Nuara
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Pavan
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Marta Radaelli
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Lucia Moiola
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Mariaemma Rodegher
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Bruno Colombo
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Ignacio Juan Keller Sarmiento
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Martinelli
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Letizia Leocani
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.,Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Martinelli Boneschi
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy. .,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy.
| | - Giancarlo Comi
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
| | - Federica Esposito
- Department of Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy. .,Laboratory of Genetics of Complex Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy.
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Abstract
The endocannabinoid system was discovered in 1988 but has received little attention for its potential therapeutic possibilities. That has started to change, and since 2000, a significant number of clinical trials of cannabinoids, principally for the control of spasticity in multiple sclerosis, have been undertaken. These studies have been difficult because of the nature of the disease and have involved patients for whom other therapies have failed or proved inadequate. This paper outlines the background to the use of cannabinoids available and discusses the principles of practice associated with their safe use. The focus has been on nabiximols, being the most studied and the only cannabinoid that has been both adequately researched for use in multiple sclerosis and granted a license by the regulators. However, what has emerged is that the effect for many patients can be much wider than just control of spasticity. Within and outside of neurology there seems to be an expanding range of possibilities for the therapeutic use of cannabinoids.
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Affiliation(s)
- William G Notcutt
- Department of Pain Management, James Paget University Hospital, Great Yarmouth, Norfolk, NR31 6LA, UK.
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37
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Meca-Lallana JE, Hernández-Clares R, Carreón-Guarnizo E. Spasticity in multiple sclerosis and role of glatiramer acetate treatment. Brain Behav 2015; 5:e00367. [PMID: 26445705 PMCID: PMC4589813 DOI: 10.1002/brb3.367] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/28/2015] [Accepted: 06/07/2015] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Spasticity is one of the most disabling and difficult-to-treat symptoms shown by patients with multiple sclerosis, who often show a suboptimal and unsatisfactory response to classic treatment and new available nonpharmacological alternatives. Due to the progressive nature of this condition, the early management should be essential to improve long-term outcomes. METHODS We performed a narrative literature review of the contribution of spasticity to the burden of multiple sclerosis and the potential role of classic disease-modifying drugs. RESULTS Added to the underlying pathophysiology of spasticity, certain external factors and drugs such as interferon may exacerbate the existing condition, hence their awareness is crucial as part of an effective management of spasticity. Furthermore, the evidence for the effectiveness of glatiramer acetate in preventing spasticity in naïve patients and in those switching from interferon should not be ignored. CONCLUSIONS This literature review proposes the examination of spasticity and the influence of classic disease-modifying agents on the level of existing condition among the variables to be considered when deciding on therapy for multiple sclerosis in clinical practice.
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Affiliation(s)
- Jose Eustasio Meca-Lallana
- Department of Neurology, Multiple Sclerosis Unit, Hospital Clínico Universitario Virgen de la Arrixaca Carretera Madrid-Cartagena s/n, 30120, Murcia, Spain ; Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, UCAM Universidad Católica San Antonio de Murcia Campus de los Jerónimos, Guadalupe, 30107, Murcia, Spain
| | - Rocío Hernández-Clares
- Department of Neurology, Multiple Sclerosis Unit, Hospital Clínico Universitario Virgen de la Arrixaca Carretera Madrid-Cartagena s/n, 30120, Murcia, Spain ; Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, UCAM Universidad Católica San Antonio de Murcia Campus de los Jerónimos, Guadalupe, 30107, Murcia, Spain
| | - Ester Carreón-Guarnizo
- Department of Neurology, Multiple Sclerosis Unit, Hospital Clínico Universitario Virgen de la Arrixaca Carretera Madrid-Cartagena s/n, 30120, Murcia, Spain ; Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, UCAM Universidad Católica San Antonio de Murcia Campus de los Jerónimos, Guadalupe, 30107, Murcia, Spain
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Shah P. Symptomatic management in multiple sclerosis. Ann Indian Acad Neurol 2015; 18:S35-42. [PMID: 26538847 PMCID: PMC4604696 DOI: 10.4103/0972-2327.164827] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 06/26/2015] [Accepted: 06/15/2015] [Indexed: 02/02/2023] Open
Abstract
Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.
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Affiliation(s)
- Pushkar Shah
- Department of Neurology, Institute of Neurosciences, South Glasgow University Hospital NHS Trust, Glasgow, G51 4TF, United Kingdom
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Coghe G, Pau M, Corona F, Frau J, Lorefice L, Fenu G, Spinicci G, Mamusa E, Musu L, Massole S, Massa R, Marrosu MG, Cocco E. Walking improvements with nabiximols in patients with multiple sclerosis. J Neurol 2015; 262:2472-7. [DOI: 10.1007/s00415-015-7866-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/16/2015] [Accepted: 07/17/2015] [Indexed: 11/28/2022]
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40
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Feinstein A, Freeman J, Lo AC. Treatment of progressive multiple sclerosis: what works, what does not, and what is needed. Lancet Neurol 2015; 14:194-207. [PMID: 25772898 DOI: 10.1016/s1474-4422(14)70231-5] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.
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Affiliation(s)
- Anthony Feinstein
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Jenny Freeman
- Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Albert C Lo
- Departments of Neurology and Epidemiology, Brown University, Providence, RI, USA
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41
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Delta-9-tetrahydrocannabinol/cannabidiol (Sativex®): a review of its use in patients with moderate to severe spasticity due to multiple sclerosis. Drugs 2015; 74:563-78. [PMID: 24671907 DOI: 10.1007/s40265-014-0197-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) [Sativex®] is an oromucosal spray formulation that contains principally THC and CBD at an approximately 1:1 fixed ratio, derived from cloned Cannabis sativa L. plants. The main active substance, THC, acts as a partial agonist at human cannabinoid receptors (CB1 and CB2), and thus, may modulate the effects of excitatory (glutamate) and inhibitory (gamma-aminobutyric acid) neurotransmitters. THC/CBD is approved in a number of countries, including Germany and the UK, as an add-on treatment for symptom improvement in adult patients with moderate to severe spasticity due to multiple sclerosis who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. In the largest multinational clinical trial that evaluated the approved THC/CBD regimen in this population, 12 weeks' double-blind treatment with THC/CBD significantly reduced spasticity severity (primary endpoint) compared with placebo in patients who achieved a clinically significant improvement in spasticity after 4 weeks' single-blind THC/CBD treatment, as assessed by a patient-rated numerical rating scale. A significantly greater proportion of THC/CBD than placebo recipients achieved a ≥ 30% reduction (a clinically relevant reduction) in spasticity severity. The efficacy of THC/CBD has been also shown in at least one everyday clinical practice study (MOVE 2). THC/CBD was generally well tolerated in clinical trials. Dizziness and fatigue were reported most frequently during the first 4 weeks of treatment and resolved within a few days even with continued treatment. Thus, add-on THC/CBD is a useful symptomatic treatment option for its approved indication.
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42
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Riley CS, Vargas W. Multiple Sclerosis in the Elderly: Considerations in the Geriatric Population for Diagnosis and Management. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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43
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Affiliation(s)
- Raphael Rush
- Department of Internal Medicine (Rush), University of Toronto; Department of Physical Medicine and Rehabilitation, Toronto Rehabilitation Institute, and University of Toronto (Kumbhare), Toronto, Ont.
| | - Dinesh Kumbhare
- Department of Internal Medicine (Rush), University of Toronto; Department of Physical Medicine and Rehabilitation, Toronto Rehabilitation Institute, and University of Toronto (Kumbhare), Toronto, Ont
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44
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Güner S, Hagharı S, Inanıcı F, Alsancak S, Aytekın G. Knee muscle strength in multiple sclerosis: relationship with gait characteristics. J Phys Ther Sci 2015; 27:809-13. [PMID: 25931736 PMCID: PMC4395720 DOI: 10.1589/jpts.27.809] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/24/2014] [Indexed: 11/24/2022] Open
Abstract
[Purpose] To investigate the relationship between isokinetic knee muscle strength and kinematic, kinetic and spatiotemporal gait parameters of patients with multiple sclerosis (MS). [Subjects and Methods] Twenty-nine MS patients (mean age 31.5±6.5) were investigated in this study. The isokinetic knee muscle strength and gait parameters of MS patients with moderate and severe disability, as determined by the expanded disability status scale (EDSS): EDSS=1-4.5 (n=22, moderate disability) and EDSS>4.5 (n=7, severe disability) were measured. [Results] Isokinetic knee muscle strength, kinematic, kinetic and spatiotemporal gait parameters differed between moderate (EDSS=1-4.5, n=22) and severe disability (EDSS>4.5, n=7). The correlation between each of gait speed, stride length, total range of knee joint movement and the four strength parameters (minimum and maximum quadriceps and hamstring muscle strengths) were significant for the MS group as a whole. Within subgroups, the correlation between minimum hamstring strength and total range of knee movement was significant only in group EDSS>4.5; minimum hamstring correlated with peak knee extensor moment in group EDSS=1-4.5, but at a reduced level of significance. [Conclusion] The present study revealed significant correlations between gait characteristics and isokinetic strength parameters of the quadriceps and hamstring muscles. Our study suggests that rehabilitation protocols for MS patients should include a critical strength training programme particularly for the hamstring and quadriceps muscles.
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Affiliation(s)
- Senem Güner
- Department of Prosthetics and Orthotics, Vocational School
of Health Services, Ankara University, Turkey
| | - Sema Hagharı
- Department of Physical Therapy and Rehabilitation, Erzurum
Regional Training and Research Hospital, Turkey
| | - Fatma Inanıcı
- Department of Physical Therapy and Rehabilitation,
Hacettepe University, Turkey
| | - Serap Alsancak
- Department of Prosthetics and Orthotics, Vocational School
of Health Services, Ankara University, Turkey
| | - Gokhan Aytekın
- Department of Prosthetics and Orthotics, Vocational School
of Health Services, Ankara University, Turkey
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45
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Cameron MH, Bethoux F, Davis N, Frederick M. Botulinum toxin for symptomatic therapy in multiple sclerosis. Curr Neurol Neurosci Rep 2015; 14:463. [PMID: 24952479 DOI: 10.1007/s11910-014-0463-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Botulinum toxin (BT) is a neurotoxin that paralyzes muscles by inhibiting release of acetylcholine from presynaptic vesicles at the neuromuscular junction. In people with multiple sclerosis (MS), clinical experience and research studies show that local injection of minute quantities of BT can temporarily control skeletal muscle spasticity, bladder detrusor hyperreflexia, and tremor. Specifically, BT injections have been shown to reduce muscle tone and improve passive function, and possibly improve active function, in patients with spasticity. Injection of BT into the bladder wall is a uniquely effective, safe, and durable treatment in patients with neurogenic detrusor hyperreflexia due to MS who have insufficient response or who do not tolerate oral antimuscarinic medications. This procedure has markedly reduced the need for indwelling catheters and bladder surgery. In addition, a recent study suggests BT may be effective for select patients with MS-associated upper extremity tremor. Appropriate use of BT can improve quality of life for many patients with MS.
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Affiliation(s)
- Michelle H Cameron
- Neurology Department, Oregon Health & Science University and Portland VA Medical Center, 3181 SW Sam Jackson Park Rd, L226, Portland, OR, USA,
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46
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Abstract
PURPOSE OF REVIEW Both acute and chronic spinal cord disorders present multisystem management problems to the clinician. This article highlights key issues associated with chronic spinal cord dysfunction. RECENT FINDINGS Advances in symptomatic management for chronic spinal cord dysfunction include use of botulinum toxin to manage detrusor hyperreflexia, pregabalin for management of neuropathic pain, and intensive locomotor training for improved walking ability in incomplete spinal cord injuries. SUMMARY The care of spinal cord dysfunction has advanced significantly over the past 2 decades. Management and treatment of neurologic and non-neurologic complications of chronic myelopathies ensure that each patient will be able to maximize their functional independence and quality of life.
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Di Marzo V, Centonze D. Placebo effects in a multiple sclerosis spasticity enriched clinical trial with the oromucosal cannabinoid spray (THC/CBD): dimension and possible causes. CNS Neurosci Ther 2014; 21:215-21. [PMID: 25475413 DOI: 10.1111/cns.12358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/26/2022] Open
Abstract
Regulatory authorities admit clinical studies with an initial enrichment phase to select patients that respond to treatment before randomization (Enriched Design Studies; EDSs). The trial period aims to prevent long-term drug exposure risks in patients with limited chances of improvement while optimizing costs. In EDSs for symptom control therapies providing early improvements and without a wash-out period, it is difficult to show further improvements and thus large therapeutic gains versus placebo. Moreover, in trials with cannabinoids, the therapeutic gains can be further biased in the postenrichment randomized phase because of carryover and other effects. The aims of the present review article are to examine the placebo effects in the enrichment and postenrichment phases of an EDS with Δ(9) -tetrahydrocannabinol and cannabidiol (THC/CBD) oromucosal spray in patients with multiple sclerosis (MS) spasticity and to discuss the possible causes of maintained efficacy after randomization in the placebo-allocated patients. The overall mean therapeutic gain of THC/CBD spray over placebo in resistant MS spasticity after 16 weeks can be estimated as a ~1.27-point improvement on the spasticity 0-10 Numerical Rating Scale (NRS; ~-20.1% of the baseline NRS score). We conclude that careful interpretation of the results of EDSs is required, especially when cannabinoid-based medications are being investigated.
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Affiliation(s)
- Vincenzo Di Marzo
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Pozzuoli, Naples, Italy
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48
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Brenner P, Alexanderson K, Björkenstam C, Hillert J, Jokinen J, Mittendorfer-Rutz E, Tinghög P. Psychiatric diagnoses, medication and risk for disability pension in multiple sclerosis patients; a population-based register study. PLoS One 2014; 9:e104165. [PMID: 25093730 PMCID: PMC4122497 DOI: 10.1371/journal.pone.0104165] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/04/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Psychiatric comorbidity is common among multiple sclerosis (MS) patients. The majority of MS patients of working ages are on disability pension. The aims of this study were to chart the prevalences of psychiatric diagnoses and medications among MS patients of working ages, and to investigate their association with the risk for future disability pension. METHODS This nationwide, population-based prospective cohort study includes 10,750 MS patients and 5,553,141 non-MS individuals who in 2005 were aged 17-64 years. Psychiatric diagnoses and medications were identified using nationwide registers. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated adjusting for socio-demographics. Furthermore, a survival analysis with five-year follow-up was performed among the 4,571 MS patients not on disability pension in 2005, with psychiatric diagnoses and medication as risk factors, and disability pension as the outcome. RESULTS Among MS patients, 35% had been prescribed psychiatric medication compared to 10% of non-MS individuals, adjusted OR 3.72 (95% CI 3.57 to 3.88). Ten percent of MS patients had received a psychiatric diagnosis, compared to 5.7% of non-MS individuals, OR 1.82 (95% CI 1.71 to 1.94). Serotonin reuptake inhibitors (SSRIs), were the most commonly prescribed drugs (17%) among MS patients, while depression (4.8%) was the most common psychiatric diagnosis. In the survival analysis, MS patients with any psychiatric diagnosis had a hazard ratio (HR) of 1.83 (95% CI 1.53 to 2.18) for disability pension compared to other MS patients. MS patients with any psychiatric drug prescription had a HR for disability pension of 2.09 (95% CI 1.84 to 2.33). CONCLUSION Psychiatric diagnoses and medications are common among MS patients and adversely affect risk for disability pension. This highlights the importance of correct diagnosis and management of psychiatric comorbidity, in a clinical as well as in a societal perspective.
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Affiliation(s)
- Philip Brenner
- Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Alexanderson
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Björkenstam
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Division of Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jussi Jokinen
- Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ellenor Mittendorfer-Rutz
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Petter Tinghög
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Henze T, von Mackensen S, Lehrieder G, Zettl UK, Pfiffner C, Flachenecker P. Linguistic and psychometric validation of the MSSS-88 questionnaire for patients with multiple sclerosis and spasticity in Germany. Health Qual Life Outcomes 2014; 12:119. [PMID: 25080934 PMCID: PMC4148533 DOI: 10.1186/s12955-014-0119-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 07/18/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory disease where many of the patients suffer from spasticity impacting their quality-of-life. The purpose of this paper was to linguistically validate and psychometrically test the Multiple Sclerosis Spasticity Scale (MSSS-88) in German speaking MS patients. METHODS The study had two stages: 1) forward/backward translations of the original MSSS-88 scale into German, discussions with MS-experts and cognitive debriefings with MS patients; 2) psychometric evaluation of the German version. Data collection took part in an observational multi-centre study in Germany (MOVE2). RESULTS The German translation of the MSSS-88 scale was discussed with three MS-experts; followed by two cognitive debriefing sessions with 12 MS patients. For psychometric evaluation the MSSS-88 was filled in by 87 MS patients with a mean age of 50.2 ± 10.4 years; 26.4% of them had severe spasticity. Data quality was acceptable. Missing data for items of the MSSS-88 were low (range 0-5.75%). Psychometric testing of the MSSS-88 revealed excellent values for reliability and validity. Significant differences between groups regarding severity, grading, type and self-ratings of MS-spasticity and sleep disturbances were found. Sensitivity to change could be demonstrated for the MSSS-88 in the group of MS patients treated with cannabinoid oromucosal spray vs. non-treated patients. In the treated group significant changes with a moderate effect size were found for 'muscle spasms', 'emotional health' and 'pain/discomfort'. No significant changes could be detected in the non-treated group. CONCLUSION Preliminary evidence from this small study supports reliability, validity, and responsiveness of the German version of the MSSS-88 for measuring the impact of spasticity in MS.
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Affiliation(s)
| | - Sylvia von Mackensen
- Institute of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany.
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50
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Koehler J. Who benefits most from THC:CBD spray? Learning from clinical experience. Eur Neurol 2014; 71 Suppl 1:10-5. [PMID: 24457847 DOI: 10.1159/000357743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with multiple sclerosis (MS) represent a diverse and heterogeneous population varying in terms of disease type, its severity and variable progression/time-course, and with regard to the wide range of presenting symptoms. Consequently, detailed experience with individual patients is important to provide examples of therapy to specific patient types. In this article, real-life data from clinical practice showing specific aspects relating to use of 9-delta-tetrahydocannabinol and cannabidiol (THC:CBD) oromucosal spray (Sativex®) in patients with moderate to severe spasticity resistant to usual therapy will be presented. Three common clinical scenarios will be considered: MS patients with resistance to usual spasticity therapies; patients with impairment in MS spasticity symptoms; MS patients with relevant impairment in quality of life/activities of daily living (QoL/ADL). These case reports highlight the diverse nature of the MS spasticity population and they show the possible usefulness of THC:CBD oromucosal spray in individual patients with moderate to severe spasticity resistant to existing therapies, within the frame of use approved after large clinical trial results. Perhaps the most important finding is the possibility of obtaining relevant improvements in QoL/ADL in some patients with resistant MS spasticity, allowing them to engage back in physical and social activities.
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Affiliation(s)
- Jürgen Koehler
- Marianne-Strauss-Klinik, Behandlungszentrum Kempfenhausen, Berg, Germany
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