Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2016 Oct 6;10(10):CD010362.
doi: 10.1002/14651858.CD010362.pub2.

Pharmacological interventions other than botulinum toxin for spasticity after stroke

Cameron Lindsay  1 , Aphrodite Kouzouna, Christopher Simcox, Anand D Pandyan
Affiliations
Meta-Analysis

Pharmacological interventions other than botulinum toxin for spasticity after stroke

Cameron Lindsay et al. Cochrane Database Syst Rev. .

Abstract

Background: The long-term risk of stroke increases with age, and stroke is a common cause of disability in the community. Spasticity is considered a significantly disabling impairment that develops in people who have had a stroke. The burden of care is higher in stroke survivors who have spasticity when compared with stroke survivors without spasticity with regard to treatment costs, quality of life, and caregiver burden.

Objectives: To assess if pharmacological interventions for spasticity are more effective than no intervention, normal practice, or control at improving function following stroke.

Search methods: We searched the Cochrane Stroke Group Trials Register (May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 5), MEDLINE (1946 to May 2016), Embase (2008 to May 2016), CINAHL (1982 to May 2016), AMED (1985 to May 2016), and eight further databases and trial registers. In an effort to identify further studies, we undertook handsearches of reference lists and contacted study authors and commercial companies.

Selection criteria: We included randomised controlled trials (RCTs) that compared any systemically acting or locally acting drug versus placebo, control, or comparative drug with the aim of treating spasticity.

Data collection and analysis: Two review authors independently assessed the studies for inclusion and extracted the data. We assessed the included studies for both quality and risk of bias. We contacted study authors to request further information when necessary.

Main results: We included seven RCTs with a total 403 participants. We found a high risk of bias in all but one RCT. Two of the seven RCTs assessed a systemic drug versus placebo. We pooled data on an indirect measure of spasticity (160 participants) from these two studies but found no significant effect (odds ratio (OR) 1.66, 95% confidence interval (CI) 0.21 to 13.07; I2 = 85%). We identified a significant risk of adverse events per participant occurring in the treatment group versus placebo group (risk ratio (RR) 1.65, 95% CI 1.12 to 2.42; 160 participants; I2 = 0%). Only one of these studies used a functional outcome measure, and we found no significant difference between groups.Of the other five studies, two assessed a systemic drug versus another systemic drug, one assessed a systemic drug versus local drug, and the final two assessed a local drug versus another local drug.

Authors' conclusions: The lack of high-quality RCTs limited our ability to make specific conclusions. Evidence is insufficient to determine if systemic antispasmodics are effective at improving function following stroke.

PubMed Disclaimer

Conflict of interest statement

CL, CS, and ADP have previously received unconditional funding from Allergan and Ipsen drug companies. ADP has also received unconditional funding from Merz drug company.

AK has no known declarations of interest. In accordance with Cochrane's policy on commercial sponsorship, no money was received from a commercial source to fund this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Systemic drug versus placebo, Outcome 1 Function.
1.2
1.2. Analysis
Comparison 1 Systemic drug versus placebo, Outcome 2 Spasticity ‐ indirect measure.
1.3
1.3. Analysis
Comparison 1 Systemic drug versus placebo, Outcome 3 Adverse events.
2.1
2.1. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 1 Function.
2.2
2.2. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 2 Function dichotomous.
2.3
2.3. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 3 Spasticity ‐ indirect measure.
2.4
2.4. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 4 Clonus.
2.5
2.5. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 5 Muscle spasms.
2.6
2.6. Analysis
Comparison 2 Systemic drug versus another systemic drug, Outcome 6 Adverse events.
3.1
3.1. Analysis
Comparison 3 Systemically acting drug versus a locally acting drug, Outcome 1 Function.
3.2
3.2. Analysis
Comparison 3 Systemically acting drug versus a locally acting drug, Outcome 2 Adverse events.
4.1
4.1. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 1 Function.
4.2
4.2. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 2 Passive range of movement.
4.3
4.3. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 3 Spasticity ‐ neurophysiological.
4.4
4.4. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 4 Spasticity ‐ indirect measure.
4.5
4.5. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 5 Clonus.
4.6
4.6. Analysis
Comparison 4 Locally acting drug versus another locally acting drug, Outcome 6 Adverse events.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010362

References

References to studies included in this review

Bes 1988 {published data only}
    1. Bes A, Eyssette M, Pierrot‐Deseilligny E, Rohmer F, Warter JM. A multi‐centre, double‐blind trial of tizanidine, a new antispastic agent, in spasticity associated with hemiplegia. Current Medical Research and Opinion 1988;10(10):709‐18. - PubMed
Kirazli 1998 {published data only (unpublished sought but not used)}
    1. Kirazli Y, On AY, Kismali B, Aksit R. Comparison of phenol block and botulinus toxin type A in the treatment of spastic foot after stroke: a randomized, double‐blind trial. American Journal of Physical Medicine & Rehabilitation 1998; Vol. 77, issue 6:510‐5. - PubMed
    1. On AY, Kirazli Y, Kismali B, Aksit R. Mechanisms of action of phenol block and botulinus toxin type A in relieving spasticity: electrophysiologic investigation and follow‐up. American Journal of Physical Medicine & Rehabilitation 1999;78(4):344‐9. - PubMed
Kocabas 2010 {published data only (unpublished sought but not used)}
    1. Kocabas H, Salli A, Demir AH, Ozerbil OM. Comparison of phenol and alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle for treatment of spastic foot after stroke: a randomized controlled pilot study. European Journal of Physical & Rehabilitation Medicine 2010;46(1):5‐10. - PubMed
Medici 1989 {published data only}
    1. Medici M, Pebet M, Ciblis D. A double‐blind, long‐term study of tizanidine ('Sirdalud') in spasticity due to cerebrovascular lesions. Current Medical Research and Opinion 1989;11(6):398‐407. - PubMed
Simpson 2009 {published data only (unpublished sought but not used)}
    1. Simpson DM, Gracies JM, Yablon SA, Barbano R, Brashear A, Team TBS. Botulinum neurotoxin versus tizanidine in upper limb spasticity: a placebo‐controlled study. Journal of Neurology, Neurosurgery & Psychiatry 2009;80(4):380‐5. - PubMed
Stamenova 2005 {published data only (unpublished sought but not used)}
    1. Stamenova P, Koytchev R, Kuhn K, Hansen C, Horvath F, Ramm S, et al. A randomized, double‐blind, placebo‐controlled study of the efficacy and safety of tolperisone in spasticity following cerebral stroke. European Journal of Neurology 2005;12(6):453‐61. - PubMed
Yazdchi 2013 {published data only (unpublished sought but not used)}
    1. Yazdchi M, Ghasemi Z, Moshayedi H, Rikhtegar R, Mostafayi S, Mikailee H, et al. Comparing the efficacy of botulinum toxin with tizanidine in upper limb post stroke spasticity. Iranian Journal of Neurology 2013;12(2):47‐50. - PMC - PubMed

References to studies excluded from this review

Basmajian 1984 {published data only}
    1. Basmajian JV, Shankardass K, Russell D. Ketazolam treatment for spasticity: double‐blind study of a new drug. Archives of Physical Medicine and Rehabilitation 1984;65(11):698‐701. - PubMed
Bovier 1985 {published data only}
    1. Bovier P, Cambier J, Morselli PL. Double‐blind trial of progabide in the treatment of spastic syndrome. Therapie 1985;40(3):181‐5. - PubMed
Burke 1975 {published data only}
    1. Burke D, Hammond C, Skuse N, Jones RF. A phenothiazine derivative in the treatment of spasticity. Journal of Neurology, Neurosurgery & Psychiatry 1975; Vol. 38, issue 5:469‐74. - PMC - PubMed
Burt 1978 {published data only}
    1. Burt AA, Currie S. A double blind controlled trial of baclofen and diazepam in spasticity due to cerebrovascular lesions. Baclofen: Spasticity and Cerebral Pathology. 1st Edition. Cambridge: Cambridge Medical, 1978:77‐9.
Caruso 1977 {published data only}
    1. Caruso G, Fels A, Santoro L, Perretti A. Effects of dantrolene sodium on pyramidal hypertonia. Clinico‐electrophysiological study. Acta Neurologica 1977; Vol. 32, issue 6:872‐83. - PubMed
Chipman 1974 {published data only}
    1. Chipman M, Kaul S, Lambie M. Efficacy of dantrolene sodium in the treatment of spasticity. Diseases of the Nervous System 1974;35(9):427‐31. - PubMed
Civardi 1994 {published data only}
    1. Civardi C, Naldi P, Cantello R, Gianelli M, Mutani R. Protirelin tartrate (TRH‐T) in upper motoneuron syndrome: a controlled neurophysiological and clinical study. Italian Journal of Neurological Sciences 1994;15(8):395‐406. - PubMed
Glass 1974 {published data only}
    1. Glass A, Hannah A. A comparison of dantrolene sodium and diazepam in the treatment of spasticity. Paraplegia 1974; Vol. 12, issue 3:170‐4. - PubMed
Harvey 1974 {published data only}
    1. Harvey MS. A comparative trial of dimethothiazine in spastic conditions. A report from the General Practitioner Research Group. Practitioner 1974;213:101‐5. - PubMed
Katrak 1992 {published data only}
    1. Katrak PH, Cole AM, Poulos CJ, McCauley JC. Objective assessment of spasticity, strength, and function with early exhibition of Dantrolene sodium after cerebrovascular accident: a randomized double‐blind study. Archives of Physical Medicine and Rehabilitation 1992; Vol. 73, issue 1:4‐9. - PubMed
Knutsson 1982 {published data only}
    1. Knutsson E, Martensson A, Gransberg L. Antiparetic and antispastic effects induced by tizanidine in patients with spastic paresis. Journal of the Neurological Sciences 1982;53(2):187‐204. - PubMed
Manca 2010 {published data only}
    1. Manca M, Merlo A, Ferraresi G, Cavazza S, Marchi P. Botulinum toxin type A versus phenol. A clinical and neurophysiological study in the treatment of ankle clonus. European Journal of Physical and Rehabilitation Medicine 2010;46(1):11‐8. - PubMed
Maupas 2004 {published data only}
    1. Maupas E, Marque P, Roques CF, Simonetta‐Moreau M. Modulation of the transmission in group II heteronymous pathways by tizanidine in spastic hemiplegic patients. Journal of Neurology, Neurosurgery & Psychiatry 2004;75(1):130‐5. - PMC - PubMed
Medaer 1991 {published data only}
    1. Medaer R, Hellebuyk H, Brande E, Saxena V, Thijs M, Kovacs L, et al. Treatment of spasticity due to stroke. A double‐blind, cross‐over trial comparing baclofen with placebo. Acta Therapeutica 1991;17(4):323‐31.
Meythaler 2001 {published data only}
    1. Meythaler JM, Guin‐Renfroe S, Brunner RC, Hadley MN. Intrathecal baclofen for spastic hypertonia from stroke. Stroke. Department of Physical Medicine and Rehabilitation, Division of Neurological Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, USA. JMeythal@uab.edu, 2001; Vol. 32, issue 9:2099‐109. - PubMed
Meythaler 2001a {published data only}
    1. Meythaler JM, Guin‐Renfroe S, Johnson A, Brunner RM. Prospective assessment of tizanidine for spasticity due to acquired brain injury. Archives of Physical Medicine and Rehabilitation 2001; Vol. 82, issue 9:1155‐63. - PubMed
Monster 1973 {published data only}
    1. Monster AW, Herman R, Meeks S, McHenry J. Cooperative study for assessing the effects of a pharmacological agent on spasticity. American Journal of Physical Medicine 1973; Vol. 52, issue 4:163‐88. - PubMed
Monster 1974 {published data only}
    1. Monster AW. Spasticity and the effect of dantrolene sodium. Archives of Physical Medicine and Rehabilitation 1974; Vol. 55, issue 8:373‐83. - PubMed
Thompson 1966 {published data only}
    1. Thompson J. Carisoprodol in the treatment of muscle spasticity in the elderly. Gerontologia Clinica 1966;8(2):100‐5. - PubMed

References to studies awaiting assessment

Arbizu 1988 {published data only}
    1. Arbizu Tx, Martinez JA, Rubio F, Aguilar M, Perez J. Clinical evaluation and tolerance of tizanidine (DS 103‐282) and baclofen in patients with chronic spasticity due to cerebrovascular accidents. Revista Espanola de Neurologia 1988;3:291‐6.
Cui 2009 {published data only}
    1. Cui L‐H, Zhang T, Yang L‐Y. Efficacy of three antispasmodics on limb spasticity in patients after stroke: a comparative analysis. Chinese Journal of Cerebrovascular Diseases 2009;6(9):466‐70.
Gan 2004 {published data only (unpublished sought but not used)}
    1. Gan Z, Xiao W‐M, Chen Y‐K. Eperisone in the treatment of hypermyotonia following stroke: a randomised controlled observation. Chinese Journal of Clinical Rehabilitation 2004;8(13):2412‐3.
Gekht 1998 {published data only}
    1. Gekht AB, Burd GS, Selikhova MV, Iaish F, Beliakov VV. Disorders of muscle tonus and their treatment with sirdalud in patients in the early recovery period of ischemic stroke. Zhurnal Nevrologii I Psikhiatrii Imeni SS Korsakova 1998;98(10):22‐9. - PubMed
Kim 2003 {published data only (unpublished sought but not used)}
    1. Kim DY, Park C, Na S, Park YS. Quantitative assessment of the effect of tizanidine on spasticity in stroke patients. Journal of the Korean Academy of Rehabilitation Medicine 2003;27:471‐9.
Kovalchuk 2008 {published data only (unpublished sought but not used)}
    1. Kovalchuk VV, Skoromets AA, Vasil'eva IV. Comparative efficacy of different muscle relaxants in the rehabilitation of post‐stroke patients with spasticity. Zhurnal Nevrologii I Psikhiatrii Imeni SS Korsakova 2008;108(8):14‐9. - PubMed
Kovalchuk 2013 {published data only}
    1. Kovalchuk VV. Evaluation of efficacy and safety of Mydocalm in the early rehabilitation of stroke. Zhurnal Nevrologii I Psihiatrii Imeni SS Korsakova 2013; Vol. 113, issue 4:35‐40. - PubMed
Musiol 1977 {published data only}
    1. Musiol A, Kazibutowska Z, Kurzbauer H. Lioresal in the treatment of hemiplegia. Clinical and electromyographic evaluation. Preliminary report. Neurologia i Neurochirurgia Polska 1977;11(6):661‐7. - PubMed
Prati 1974 {published data only}
    1. Prati R, Soriani S. Use of beta‐(p‐clorophenil)‐gamma‐aminobutirric acid in the treatment of hemiplegic patients with hypertonius. Rivista di Patologia Nervosa e Mentale 1974;95(5):651‐2. - PubMed
Stamenova 2006 {published data only}
    1. Stamenova P, Koytchev R, Kuhn K, Hanasen C, Horvath F, Ramm S, et al. A randomized, double blind, placebo‐controlled study of the efficacy and safety of tolperisone in spasticity following cerebral stroke. Zhurnal Nevrologii I Psikhiatrii Imeni SS Korsakova 2006; Vol. 106, issue 1:34‐42. - PubMed
Weynants 1990 {published data only}
    1. Weynants L, Laere M. Tizanidine in the treatment of spasticity in patients with hemiplegia caused by CVA or brain trauma. Acta Belgica Medica Physica 1990;13(1):19‐22. - PubMed
Yao 2004 {published data only (unpublished sought but not used)}
    1. Yao J‐R, Wang D‐S, Ni X‐B, Rong D‐M, Zheng H‐M. Efficacy of baclofen combined with rehabilitation training in stroke patients with spastic hemiplegia. Chinese Journal of Clinical Rehabilitation 2004;8(10):1814‐5.

Additional references

Ada 2006
    1. Ada L, O'Dwyer N, O'Neill E. Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: an observational study. Disability & Rehabilitation 2006;28(13):891‐7. - PubMed
Adamson 2004
    1. Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability?. Journal of Stroke and Cerebrovascular Diseases 2004; Vol. 13, issue 4:171‐7. - PubMed
Barnes 1998
    1. Barnes MP. Management of spasticity. Age and Ageing 1998;27(2):239‐45. - PubMed
Bogey 2004
    1. Bogey RA, Geis CC, Bryant PR, Moroz A, O'Neill BJ. Stroke and neurodegenerative disorders. 3. Stroke: rehabilitation management. Archives of Physical Medicine and Rehabilitation 2004;85(3):S15‐20, S34‐40. - PubMed
Burke 1988
    1. Burke D. Spasticity as an adaptation to pyramidal tract injury. Advances in Neurology 1988;47:401. - PubMed
Daniel 1999
    1. Daniel WW. Biostatistics: A Foundation for Analysis in the Health Sciences. 7th Edition. London: Wiley and Sons, 1999.
Davidoff 1985
    1. Davidoff RA. Antispasticity drugs: mechanisms of action. Annals of Neurology 1985;17(2):107‐16. - PubMed
Deeks 2011
    1. Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 9: Analysing data and undertaking meta‐analyses. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Esquenazi 2011
    1. Esquenazi A. The human and economic burden of poststroke spasticity and muscle overactivity. Journal of Clinical Outcomes Management 2011;18(1):34‐44.
Fleuren 2010
    1. Fleuren JF, Voerman GE, Erren‐Wolters CV, Snoek GJ, Rietman JS, Hermens HJ, et al. Stop using the Ashworth scale for the assessment of spasticity. Journal of Neurology, Neurosurgery & Psychiatry 2010;81(1):46‐52. - PubMed
Gallichio 2004
    1. Gallichio JE. Pharmacologic management of spasticity following stroke. Physical Therapy 2004;84(10):973‐81. - PubMed
Gormley 1997
    1. Gormley ME, O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity. Muscle and Nerve Supplement 1997;20(S6):S14‐20. - PubMed
Gracies 1997
    1. Gracies JM, Nance P, Elovic E, McGuire J, Simpson DM. Traditional pharmacological treatments for spasticity. Part II: General and regional treatments. Muscle & Nerve Supplement. Wiley, 1997; Vol. 20, issue S6:S92‐120. - PubMed
Higgins 2002
    1. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Statistics in Medicine 2002;21(11):1539‐58. - PubMed
Higgins 2011
    1. Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Howe 1987
    1. Howe JR, Sutor B, Zieglgänsberger W. Baclofen reduces post‐synaptic potentials of rat cortical neurones by an action other than its hyperpolarizing action. Journal of Physiology 1987;384:539‐69. - PMC - PubMed
Krach 2001
    1. Krach LE. Pharmacotherapy of spasticity: oral medications and intrathecal baclofen. Journal of Child Neurology 2001;16(1):31‐6. - PubMed
Lyons 2007
    1. Lyons BE, Moore P, Bhakta BB, Bamford JM, Cardwell C, Logan ID. Botulinum toxin for adult spasticity after stroke or non‐progressive brain lesion [Protocol withdrawn 2013]. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD002926.pub2] - DOI
Malhotra 2008
    1. Malhotra S, Cousins E, Ward A, Day C, Jones P, Roffe C, et al. An investigation into the agreement between clinical, biomechanical and neurophysiological measures of spasticity. Clinical Rehabilitation 2008;22(12):1105‐15. - PubMed
Malhotra 2009
    1. Malhotra S, Pandyan AD, Day CR, Jones PW, Hermens H. Spasticity, an impairment that is poorly defined and poorly measured. Clinical Rehabilitation 2009;23(7):651‐8. - PubMed
Mirbagheri 2011
    1. Mirbagheri MM, Lilaonitkul T, Rymer WZ. Prediction of natural history of neuromuscular properties after stroke using Fugl‐Meyer scores at 1 month. Neurorehabilitation and Neural Repair 2011;25(5):458‐68. - PubMed
Moher 2009
    1. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. Annals of Internal Medicine 2009;151(4):264. - PubMed
Monaghan 2011
    1. Monaghan K, Horgan F, Blake C, Cornall C, Hickey PPM, Lyons BE, et al. Physical treatment interventions for managing spasticity after stroke. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD009188] - DOI
Montane 2004
    1. Montane E, Vallano A, Laporte JR. Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review. Neurology 2004;63:1357‐63. - PubMed
Mukherjee 2010
    1. Mukherjee A, Chakravarty A. Spasticity mechanisms ‐ for the clinician. Frontiers in Neurology 2010;1:149. - PMC - PubMed
Olvey 2010
    1. Olvey EL, Armstrong EP, Grizzle AJ. Contemporary pharmacologic treatments for spasticity of the upper limb after stroke: a systematic review. Clinical Therapeutics 2010;32(14):2282‐303. - PubMed
Palmeri 1990
    1. Palmeri A, Wiesendanger M. Concomitant depression of locus coeruleus neurons and of flexor reflexes by an alpha 2‐adrenergic agonist in rats: a possible mechanism for an alpha 2‐mediated muscle relaxation. Neuroscience 1990;34(1):177‐87. - PubMed
Pandyan 1999
    1. Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified Ashworth scales as measures of spasticity. Clinical Rehabilitation 1999;13(5):373‐83. - PubMed
Pandyan 2005
    1. Pandyan AD, Gregoric M, Barnes MP, Wood D, Wijck F, Burridge J, et al. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disability & Rehabilitation 2005;27(1):2‐6. - PubMed
Rekand 2010
    1. Rekand T. Clinical assessment and management of spasticity: a review. Acta Neurologica Scandinavica 2010;122 Suppl 190:62‐6. - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Royal College of Physicians 2009
    1. Royal College of Physicians, British Society of Rehabilitation Medicine, Chartered Society of Physiotherapy, Association of Chartered Physiotherapists Interested in Neurology. Spasticity in Adults: Management Using Botulinum Toxin. National Guidelines. London: RCP, 2009.
Seshadri 2006
    1. Seshadri S, Beiser A, Kelly‐Hayes M, Kase CS, Au R, Kannel WB, et al. The lifetime risk of stroke. Stroke 2006;37(2):345‐50. - PubMed
Sheean 2006
    1. Sheean G. Botulinum toxin treatment of adult spasticity: a benefit‐risk assessment. Drug Safety 2006;29(1):31‐48. - PubMed
Sheean 2009
    1. Sheean G. Botulinum toxin should be first‐line treatment for poststroke spasticity. Journal of Neurology, Neurosurgery & Psychiatry 2009;80(4):359. - PubMed
Sheean 2010
    1. Sheean G, Lannin NA, Turner‐Stokes L, Rawicki B, Snow BJ. Botulinum toxin assessment, intervention and after‐care for upper limb hypertonicity in adults: international consensus statement. European Journal of Neurology 2010;17:74‐93. - PubMed
Sorinola 2009
    1. Sorinola IO, White CM, Rushton DN, Newham DJ. Electromyographic response to manual passive stretch of the hemiplegic wrist: accuracy, reliability, and correlation with clinical spasticity assessment and function. Neurorehabilitation and Neural Repair 2009;23(3):287‐94. - PubMed
van Tulder 1997
    1. Tulder MW, Assendelft WJJ, Koes BW, Bouter LM, the Editorial Board of The Cochrane Collaboration Back Review Group. Method guidelines for systematic reviews in The Cochrane Collaboration Back Review Group for Spinal Disorders. Spine 1997;22(20):2323‐30. - PubMed
Vora 2010
    1. Vora A. Tolperisone. Journal of the Association of Physicians of India 2010;58:127‐8. - PubMed
Watkins 2002
    1. Watkins CL, Leathley MJ, Gregson JM, Moore AP, Smith TL, Sharma AK. Prevalence of spasticity post stroke. Clinical Rehabilitation 2002;16(5):515‐22. - PubMed
Willerslev‐Olsen 2011
    1. Willerslev‐Olsen M, Lundbye‐Jensen J, Petersen T, Nielsen J. The effect of baclofen and diazepam on motor skill acquisition in healthy subjects. Experimental Brain Research 2011; Vol. 213, issue 4:465‐74. - PubMed

Publication types

MeSH terms