Clinical Guidelines from ACP

Featured Clinical Guideline

Diagnosis of Obstructive Sleep Apnea in Adults

Full text

Recent Guidelines Topics from ACP

Screening Pelvic Examination in Adult Women

Full text
View ACP Guidelines on your smartphone. Mobile

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.

Access all Guidelines

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.


Of Interest and Note...

Online High Value Cases
  • Online High Value Cases: A series of High Value Care case studies are available for free to help clinicians understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care that improves health and eliminates wasteful practices.
  • ACP's Mobile Resources include a variety of applications, mobile web resources, and mobile documents to support your clinical practice.

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.

Q.

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.
ACP Clinical Shorts
An affordable and convenient way to earn MOC points and CME credit on the go.
Selected ACP Member Benefits
ACP JournalWise
ACP JournalWise

Online and optimized for mobile use, ACP JournalWise alerts you to the highest quality, most clinically relevant new articles in your preferred areas of specialty and with a frequency that you select.

Begin Search | Learn More

ACP Smart Medicine
ACP Smart MedicineSM

Authoritative, evidence-based guidance to improve clinical care. Earn free CME credit using ACP's new clinical decision support tool.

Sign In | Learn More

In the Clinic
In the Clinic

Evidence-based answers to frequently asked questions about screening, prevention, diagnosis, and therapy for common clinical conditions. Plus, downloadable slide sets to improve quality of care are available free to members.

In the Clinic | Access Slide Sets
Clinical Multimedia