Non-Pharmacological Interventions for Spasticity in Multiple Sclerosis

Summary

A Cochrane review [Abstract] 1 included 9 studies with a total of 301 patients with multiple sclerosis (MS) and spasticity. The trials investigated various types and intensities of non pharmacological interventions for treating spasticity, including physical activity programmes (such as physiotherapy, structured exercise programme, sports climbing); transcranial magnetic stimulation (Intermittent Theta Burst Stimulation (iTBS), Repetitive Transcranial Magnetic Stimulation (rTMS)); electromagnetic therapy (pulsed electromagnetic therapy; magnetic pulsing device), Transcutaneous Electrical Nerve Stimulation (TENS); and Whole Body Vibration (WBV). They were compared them with some form of control intervention, such as sham/placebo interventions or lower level or different types of intervention, minimal intervention, waiting list controls or no treatment and interventions given in different settings. There is low level evidence for addition of active physiotherapy after botulinum toxin injection in reducing spasticity up to 12 weeks (Modified Ashworth Scale (MAS): MD -0.95 (26.1 %) vs. -0.28 (7.7 %), p<0.01; 1 trial, n=38); iTBS as a single intervention or in combination with exercise therapy reduced spasticity after two weeks of treatment (3.3 ± 0.8 before treatment; 1.6 ± 0.8 after treatment, p< 0.05; 1 trial, n=30), short-term benefits of rTMS for improved spasticity (MAS 9.86 ± 3.13 vs. 7.14 ± 4.03, p<0.05; 1 trial, n=20), functional abilities (p<0.05 for both groups; 1 trial, n=38) and stretch reflex thresholds (4.3 ± 7.5deg/s vs. -3.8 ± 9.7deg/s, p=0.001; 1 trial, n=38) and short-term beneficial effects of pulsing magnetic fields for combined end-point of spasticity, bladder control, cognitive function, fatigue level, mobility, and vision ((-3.83 ± 1.08 vs. -0.17 ± 1.07, change in performance scale (PS), p<0.005; 1 trial, n=30). There is no evidence of benefit in the reported studies that TENS, sports climbing, and WBV (with or without an exercise programme) provide any additional improvements in spasticity in people with MS.

Comment: The quality of the evidence is downgraded by study quality (unclear allocation concealment), inconsistency (heterogeneity in treatments and comparators), imprecise results (small study size and few patients for each comparison) and indirectness (short follow-up time).