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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 39-year-old man is evaluated for a 5-month history of stiffness when walking and leg pain that is worse in the evening. He has a 7-year history of multiple sclerosis. Medications are interferon beta-1a and vitamin D.

On physical examination, temperature is 37.1°C (98.8°F), blood pressure is 125/60 mm Hg, and pulse rate is 66/min. Stiffness and tightening of the muscles in the lower extremities that are more pronounced with passive movement are noted. Reflexes are 3+ in the lower extremities with upgoing toes bilaterally. Gait examination shows a stiff-legged appearance when the patient walks.

Laboratory studies show a serum creatine kinase level of 35 units/L.


Which of the following is the most appropriate management?

This patient should receive tizanidine. The patient has multiple sclerosis (MS) and is experiencing upper motoneuron spasticity with associated muscle spasms and cramping pain. Examination findings supporting this diagnosis include movement-dependent spasticity and hyperreflexia. Patients with this type of spasticity can experience significant pain due to muscle overactivity and may also have impaired gait due to stiffness. Spasticity, spasms, and cramping usually respond to a combination of physical therapy (stretching) and oral antispasticity drugs. Tizanidine, a centrally acting α2-adrenergic agonist, exerts muscle relaxant properties by helping modulate interneuron activity and polysynaptic reflex activity. Other possible treatment options are baclofen and cyclobenzaprine. Of these three drugs, none is the clear first-line choice. Patients with severe and refractory symptoms may require trials of botulinum toxin injections or an intrathecal baclofen pump.

This patient has a normal serum creatine kinase level, upper motoneuron signs on examination, and no signs of an inflammatory myopathy (such as polymyositis) or neuromuscular disorder (such as amyotrophic lateral sclerosis) for which electromyography would be appropriate.

MRI of the lumbosacral spine only images the lower conus medullaris, cauda equina, and lumbar spinal roots. MS does not affect the lumbar spinal roots, and the clinical examination is consistent with upper motoneuron dysfunction, which would localize higher on the spinal cord or brain. Therefore, this test is inappropriate for this patient.

Oxybutynin is used to treat an overactive bladder, which can occur in patients with MS but does not significantly alter muscle tone and thus is unlikely to help in this patient.

Key Point

  • Tizanidine, baclofen, and cyclobenzaprine are appropriate treatments for multiple sclerosis-related spasticity.
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