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The trial patients (8 men) had a mean age of 46 years; 11 patients had multiple sclerosis and 7 patients had spinal cord injuries. The match patients (7 men) had a mean age of 48 years; 9 patients had multiple sclerosis and 6 patients had spinal cord injuries.
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In a double blind, randomised, multicentre trial 22 patients were followed up during 13 weeks and subsequently included in a 52 week observational longitudinal study. Patients were those with chronic, disabling spasticity who did not respond to maximum doses of oral baclofen, dantrolene, and tizanidine. After implantation of a programmable pump patients were randomly assigned to placebo or baclofen infusion for 13 weeks. After 13 weeks all patients received baclofen. Clinical efficacy was assessed by the Ashworth scale, spasm score, and self reported pain, and health related quality of life by the sickness impact profile (SIP) and the Hopkins symptom checklist (HSCL).
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The diagnosis of SPG7 is suspected in individuals with characteristic neurologic findings and is confirmed by detection of pathogenic variants in SPG7, the gene encoding the protein paraplegin. SPG7 is the only gene in which pathogenic variants are known to cause SPG7.
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Clonidine is a partial agonist at brain alpha(2)-adrenoceptors (alpha(2)AR), but also has high affinity (K(D) = 51 nM) in homogenate binding assays for non-adrenergic imidazoline-binding sites (I-sites; imidazoline receptors). Herein, an autoradiographic comparison of [3H]-clonidine binding to I-sites and alpha(2)AR in sections of human brain is reported. For I-sites, the adrenergic component of 50 nM [3H]-clonidine binding was masked with either 60 microM norepinephrine (NE; alpha(2)AR agonist) or 12.5 microM methoxy-idazoxan (MIDX; selective alpha(2)AR antagonist), whereas the remaining non-adrenergic sites were studied by displacement with 20 microM cirazoline. Levels of [3H]-clonidine binding to alpha(2)AR and I-sites, determined in adjacent tissue sections, were positively correlated across 27 brain regions (p = 0.0003; r(2) = 0.385). The principal olivary nucleus and the rostral portion of the ventrolateral medulla had highest ratios of I-sites: alpha(2)AR (>4:1). Quantitative transepts drawn across hippocampal images revealed alpha(2)AR enrichments in the CA-1 and inner molecular layers of the dentate gyrus-areas not enriched in I-sites. Competition curves were generated for I-sites in caudate sections using 10 ligands known to distinguish between I(1) and I(2) subtypes. The rank-order of affinities were cirazoline > harmane > BDF6143 > idazoxan = tizanidine (affinities of agmatine, efaroxan, moxonidine, NE, and oxymetazoline were too low to be reliable). Only the endogenous I-site ligand, harmane, had a monophasic displacement curve at the non-adrenergic sites (Ki = 521 +/- 12 nM).
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Twenty-six placebo-controlled studies (using baclofen, dantrolene, tizanidine, botulinum toxin, vigabatrin, prazepam, threonine and cannabinoids) and thirteen comparative studies met the selection criteria and were included in this review. Only fifteen of these studies used the Ashworth scale, of which only three of the eight placebo-controlled trials and none of the seven comparative studies showed a statistically significant difference between test drugs. Spasms, other symptoms and overall impressions were only assessed using unvalidated scores and results of functional assessments were inconclusive.
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Dystonia is usually a lifelong condition with persistent pain and disability. Focal dystonia affects a single part of the body; generalised dystonia can affect most or all of the body. It is more common in women, and some types of dystonia are more common in people of Ashkenazi descent.
This is a case which highlights unique diagnostic challenges in the evaluation of a previously healthy patient presenting with a myelopathy initially most concerning for malignancy. However, timely recognition and nonoperative therapy of unexpected spinal sarcoidosis with corticosteroidal therapy was crucial in averting the sequelae of undiagnosed or misdiagnosed neurosarcoidosis, which can be devastating and life-threatening. Diagnosis is challenging due to significant similarities in clinical and roentgenographic findings of spinal sarcoidosis with infection, inflammation, and malignancy. Our case demonstrates that diagnosis of spinal sarcoidosis is especially elusive when it is the initial manifestation of sarcoidosis.
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To examine adherence to baclofen, tizanidine, and dantrolene (U.S. Food and Drug Administration-approved oral spasticity medications), and identified determinants of adherence.
Group 1 showed increased CROM, increased mean NRS pain reduction, and decreased incidence of combined tension-type headache compared with group N during the follow-up. Younger patients in group 1 required a shorter treatment cycle and experienced a longer symptom-free period.
Comparator studies that assess treatment effects in a clinical setting have improved the understanding of the efficacy and tolerability of prophylactic treatments for chronic migraine (CM). It is premature to recommend device-based treatments, such as occipital nerve stimulation, vagal nerve stimulation, and patent foramen ovale closure for CM, because clinical trials are in the preliminary stages. Physical therapy techniques, like applying heat or cold packs, ultrasonography, and electrical stimulation, have been shown to lessen pain. Nonpharmacologic treatments, including cognitive behavioral therapy, stress management, and biofeedback, have been investigated and proved effective in some areas of pain management, including migraine. However, pharmacologic interventions may be necessary for effective, long-term prophylaxis. Several medications under investigation, including topiramate, gabapentin, tizanidine, and amitriptyline, have proved efficacious in reducing the number of migraine episodes and the pain associated with migraine, although adverse events may prevent continued use of some agents. Evidence supports the use of botulinum toxin type A (BoNT-A) for CM, with or without medication overuse, to achieve a significant reduction in headache episodes. Efficacy of BoNT-A for CM is comparable with or better than that of valproate and topiramate, with better tolerability. Predictors of response to BoNT-A for CM appear to include predominantly unilateral location of the headache and the presence of cutaneous or muscle allodynia. BoNT-A has been demonstrated to be safe and well tolerated, with rare discontinuations due to adverse events. Recent clinical trials indicate that rational combination therapy may have a place in treating refractory CM. Well-controlled multicenter trials are awaited.
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Glutamic and aspartic acids are the physiological mediators of most excitatory synaptic transmission. This is critical to several normal nervous system functions, including memory and long-term modification of synaptic transmission and nociception. Activation of the inotropic NMDA and non-NMDA receptors increases transmembrane calcium and sodium fluxes, and the metabotropic glutamate receptor activation results in generation of inositol triphosphate and inhibition of adenylate cyclase. Numerous modulatory sites exist, especially on the NMDA receptor. Nitric oxide, arachidonic acid, superoxide, and intracellular calcium overload are the ultimate mediators of neuronal death. Glutamate re-uptake transporters belong to a unique family of amino acid transport systems, the malfunction of which is intricately involved in disease pathogenesis. Ischemic stroke, hypoglycemia, Parkinson's disease, alcohol intoxication and withdrawal, Alzheimer's disease, epilepsy, and chronic pain syndromes are only some of the important clinical neurological disorders with a major pathogenic role for the excitatory amino acids.
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Tension-type headache (TTH) is the most prevalent form of primary headache in the general population. We discuss advances in the treatment of TTH. We briefly review nonpharmacologic therapies and then focus on current pharmacologic strategies. For acute treatment, the most common interventions involve the use of simple analgesics and anti-inflammatory medications, often taken by the patient without a prescription. For preventive treatment, amitriptyline is the best-studied drug, but nortriptyline, mirtazapine, tizanidine, the selective serotonin reuptake inhibitors, and other medications can be used. We close by discussing potential future therapies, including calcitonin gene-related peptide receptor antagonism, as well as substance P and the nitric oxide pathways.
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Tizanidine (Sirdalud) was compared to baclofen (Lioresal) in a randomized, double-blind, cross-over trial. Each medication was introduced over a three week titration period and then maintained at the highest tolerated dose for five weeks. The two treatment phases were separated by a one week drug withdrawal and a two week washout period. Sixty-six patients entered the trial and forty-eight completed both treatment phases. At the end of the trial, neurologists and physiotherapists thought that baclofen was superior on the basis of perceived efficacy and tolerance (p less than or equal to 0.05). Although the efficacy of tizanidine or baclofen was judged as good to excellent by 24 and 39% of patients respectively, this difference was not statistically significant. Muscle weakness was the most common adverse effect. This was significantly more troublesome in patients treated with baclofen. Somnolence and xerostomia were more common in patients treated with tizanidine. Both baclofen and tizanidine appear to be useful adjuncts in the treatment of spasticity in patients with multiple sclerosis. Preference of either drug is tempered principally by side-effects.
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Tizanidine, an alpha(2)-adrenoceptor agonist, is a short-acting drug with larger interpatient variability, and linear pharmacokinetics that is dosage form-dependent. Clinical trials have demonstrated that the efficacy of tizanidine is comparable to that of baclofen or diazepam with global tolerability data favoring tizanidine. A clinical case presentation demonstrated the effective use of tizanidine in combination with baclofen as a logical avenue for improved spasticity control.
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To assess the absolute and comparative efficacy and tolerability of anti-spasticity agents in multiple sclerosis (MS) patients.
A comprehensively validated procedure is presented for simultaneous semiquantitative/quantitative screening of 51 drugs of abuse or drugs potentially hazardous for traffic safety in serum, plasma or whole blood. Benzodiazepines (12), cannabinoids (3), opioids (8), cocaine, antidepressants (13), antipsychotics (5) and antiepileptics (2) as well as zolpidem, zaleplon, zopiclone, meprobamate, carisoprodol, tizanidine and orphenadrine and internal standard flurazepam, were isolated by high-yield liquid-liquid extraction (LLE). The dried extracts were derivatized by two-step silylation and analyzed by the combination of two different gas chromatographic (GC) separations with both electron capture detection (ECD) and mass spectrometry (MS) operating in a selected ion-monitoring (SIM) mode. Quantitative or semiquantitative results were obtained for each substance based on four-point calibration. In the validation tests, accuracy, reproducibility, linearity, limit of detection (LOD) and limit of quantitation (LOQ), selectivity, as well as extraction efficiency and stability of standard stock solutions were tested, and derivatization was optimized in detail. Intra- and inter-day precisions were within 2.5-21.8 and 6.0-22.5%, and square of correlation coefficients of linearity ranged from 0.9896 to 0.9999. The limit of quantitation (LOQ) varied from 2 to 2000 ng/ml due to a variety of the relevant concentrations of the analyzed substances in blood. The method is feasible for highly sensitive, reliable and possibly routinely performed clinical and forensic toxicological analyses.
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Healthy male and female subjects aged 18 to 45 years completed 2 treatment periods: one with a tizanidine 6-mg capsule administered intact and the other with capsule contents sprinkled in applesauce. The 2 treatment periods had a 6-day washout period between administrations. Plasma tizanidine concentrations were determined for blood samples collected over 24 hours after administration. All treatment-emergent adverse events were recorded and graded by intensity and relationship to the study drug (not, improbable, possible, probable, definite) by the attending physician based on his or her clinical impression.
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A total of 40 children with dysfunctional voiding were enrolled in a prospective, randomized, 2-parallel group, flexible-dose study. The evaluations were performed in accordance with the International Children's Continence Society guidelines. The children were followed up after 1 week and then monthly for 6 months for the clinical, urine culture, and urodynamic parameters. The degree of improvement was assessed using a satisfaction scale that ranged from 0 (no improvement at all) to 10 (total improvement).
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Tolfenamic acid strongly inhibited phenacetin-O-deethylation in vitro (IC(50) 1.8 microM without albumin). Albumin decreased its inhibitory effect in a concentration-dependent manner; the IC(50) exceeded 100 microM with 10 mg/ml of albumin. Tolfenamic acid had no effect on the area under the concentration-time curve (AUC(0-oo)), peak concentration, time of peak concentration or half-life of tizanidine or M-3; only the AUC(0-oo) of secondary metabolite M-4 was slightly decreased (13%, P = 0.004). The caffeine test and the pharmacodynamic effects of tizanidine were unchanged.
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One hundred forty-two patients with spastic MS who were not taking any interfering medication, such as an antispasticity drug or other alpha-noradrenergic agonist, entered the trial.
Alpha-2-adrenergic agonists, such as clonidine, produce antinociception in animal pain models after intrathecal administration. However, clinical usage is limited by cardiovascular side effects. To investigate alternative alpha(2)-adrenergic agonists as analgesics, we implanted six dogs with an intrathecal catheter and infusion pump. After baseline saline infusion, animals received clonidine or tizanidine (crossover study) each week at escalating doses of 125-750 microg/h. Analgesia, blood pressure, heart rate, respiratory rate, sedation, and coordination were evaluated. A 28-day safety study was performed with another nine dogs receiving intrathecal tizanidine (3 or 6 mg/d) or saline. Equal doses of clonidine and tizanidine produce the same antinociception in thermal withdrawal tests. Blood pressure was reduced with 125-500 microg/h of clonidine, but not with tizanidine at any dose. Clonidine 250 microg/h reduced heart rate by 45.8%, and five of six animals had bradyarrhythmias (marked bradycardia), whereas tizanidine decreased heart rate by 15.1% without arrhythmias, even at the largest dose. Respiratory rate decreased with 250 microg/h of clonidine and larger doses. Sedation or incoordination occurred only at the largest dose for either drug. The safety study indicated that 3 mg/d of tizanidine in dogs produced no side effects or histopathologic changes. Tizanidine may be a useful alternative in patients experiencing cardiovascular side effects with intrathecal infusion of clonidine.
Spasticity and other muscle symptoms in the palliative care patient can contribute to suffering, significantly detracting from overall quality of life. Current therapy primarily includes use of centrally acting muscle relaxants, which are beneficial in treating some symptoms, but frequently have extensive side effects, such as sedation and muscle weakness. Tizanidine, a central alpha 2 adrenergic agonist, has been shown in clinical studies to be as effective as other commonly used antispastic agents, but without debilitating muscle weakness. Tizanidine can cause sedation, which is minimized by dose titration. When taken at night, patients report improvement in getting to sleep and little drowsiness or "hangover sensation" upon waking. Tizanidine is potentially helpful to many palliative care patients with chronic muscle pain and sleep disturbances.
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To evaluate the therapeutic effects of the GABA analogue, pregabalin, on patients with conditions producing spasticity who had not responded to, or experienced problems with side-effects of the available anti-spasticity agents.
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A 42-year-old female patient with lower back and leg pain, severe flexor reflex responses, and a walking disorder was evaluated. Gabapentin and tizanidine were given to treat the neuropathic pain and flexor reflex responses. An exercise program was applied to improve the walking disorder. Finally, the patient's complaints of pain considerably decreased, flexor reflex responses were reduced, and a more comfortable walking motion was observed.
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In this systematic review we present information relating to the effectiveness and safety of the following interventions: ablative neurosurgical techniques to the Gasserian ganglion, baclofen, carbamazepine, clonazepam, cryotherapy of peripheral nerves, gabapentin, lamotrigine, microvascular decompression, nerve block, oxcarbazepine, peripheral acupuncture, phenytoin, proparacaine eye drops, sodium valproate, stereotactic radiosurgery, tizanidine, and topiramate.
The centrally acting muscle relaxant baclofen (3-10 mg/kg) reduced SR induced by morphine (40 mg/kg) at all used doses; tizanidine decreased the intensity of SR at highest doses tested (0.6 and 1 mg/kg). Dantrolene (20-100 mg/kg), a peripherally acting muscle relaxant, did not affect SR. Effects of serotonergic agents depended on the specific mechanism of action. SR appears to be available for rapid evaluation of the effect of antispasticity drugs.
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The diagnosis of SPG3A can be established only by molecular genetic testing of ATL1, the gene encoding the protein atlastin-1.
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The effects of alpha-adrenoceptors agents on seizures induced by intraperitoneal administration of lidocaine (75 mg/kg) were studied in mice. Pretreatment with the selective alpha 2-adrenoceptor agonist, tizanidine, decreased the incidence of seizures induced by lidocaine. Tizanidine increased the latency to the first seizure in those animals which progressed to seizures. The blockade of alpha 2-adrenoceptors with yohimbine or phentolamine counteracted the protection induced by tizanidine. The selective alpha 2-adrenoceptor antagonist, prazosin, did not modify the protection induced by tizanidine. The alpha 2-adrenoceptor agonist clonidine also increased the latency to the first seizure induced by lidocaine. The protective effect of clonidine was also reversed by pretreatment with the selective alpha 2-adrenoceptor antagonist yohimbine. Taken together, these results suggest that alpha 2-adrenoceptors are involved in seizures induced by lidocaine.
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The effects of tizanidine on the electromyographic responses of forearm flexors and extensors to torque disturbances were studied in normal subjects. Tizanidine had a strong depressive action on all the reflex responses, and on muscle background activity. It is concluded that the action on reflexes is not specific, but secondary to decreased spinal cord excitability.