Journal of Pain and Symptom Management
Volume 28, Issue 2 , Pages 140-175 , August 2004

Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review

  • Roger Chou, MD

      Affiliations

    • Corresponding Author InformationAddress reprint requests to: Roger Chou, MD, 3181 SW Sam Jackson Park Rd., Mail Code: BICC, Portland, OR 97239, USA.
  • ,
  • Kim Peterson, MS
  • ,
  • Mark Helfand, MD, MPH

,Accepted 22 November 2003.

References 

  1. Young RR. Spasticity: a review. Neurology. 1994;44(11 Suppl 9):S12–S20
  2. Andersson PB, Goodkin DE. Current pharmacologic treatment of multiple sclerosis symptoms. West J Med. 1996;165(5):313–317
  3. Burchiel KJ, Hsu FP. Pain and spasticity after spinal cord injury: mechanisms and treatment. Spine. 2001;26(24 Suppl):S146–S160
  4. Barnes MP. Medical management of spasticity in stroke. Age Ageing. 2001;30(Suppl. 1):13–16
  5. Anonymous . Spasticity. Lancet. 1989;2(8678-8679):1488–1490
  6. Leventhal LJ. Management of fibromyalgia. Ann Intern Med. 1999;131(11):850–858
  7. Redillas C, Solomon S. Prophylactic pharmacological treatment of chronic daily headache. Headache. 2000;40(2):83–102
  8. Deyo RA, Bergman J, Phillips WR. Drug therapy for back pain: Which drugs help which patients?. Spine. 1996;21(24):2840–2850
  9. Arnold LM, Keck PE, Welge JA. Antidepressant treatment of fibromyalgia. A meta-analysis and review. Psychosomatics. 2000;41(2):104–113
  10. Cherkin DC, Wheeler KJ, Barlow W, et al.  Medication use for low back pain in primary care. Spine. 1998;23(5):607–614
  11. Brogden RN, Speight TM, Avery GS. Baclofen: a preliminary report of its pharmacological properties and therapeutic efficacy in spasticity. Drugs. 1974;8(1):1–14
  12. Davidoff RA. Antispasticity drugs: mechanisms of action. Ann Neurol. 1985;17(2):107–116
  13. Wagstaff AJ, Bryson HM. Tizanidine. A review of its pharmacology, clinical efficacy and tolerability in the management of spasticity associated with cerebral and spinal disorders. Drugs. 1997;53(3):435–452
  14. Nance PW. Tizanidine: An α2-agonist imidazoline with antispasticity effects. Today's Ther Trends. 1997;15(1):11–25
  15. Kita M, Goodkin DE. Drugs used to treat spasticity. Drugs. 2000;59(3):487–495
  16. Cook JB, Nathan PW. On the site of action of diazepam in spasticity in man. J Neurol Sci. 1967;5(1):33–37
  17. Davidoff RA. Pharmacology of spasticity. Neurology. 1978;28(9 Pt 2):46–51
  18. Preston EJ, Miller CB, Herbertson RK. A double-blind, multicenter trial of methocarbamol (Robaxin) and cyclobenzaprine (Flexeril(TM)) in acute musculoskeletal conditions. Today's Ther Trends. 1984;1(4):1–11
  19. Reeves RR, Carter OS, Pinkofsky HB, et al.  Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis. 1999;18(2):51–56
  20. Azoury FJ. Double-blind study of Parafon Forte and Flexeril in the treatment of acute skeletal muscle disorders. Curr Ther Res. 1979;26:189–197
  21. Gold RH. Orphenadrine citrate: Sedative or muscle relaxant?. Clin Ther. 1978;1(6):451–453
  22. Smith HS, Barton AE. Tizanidine in the management of spasticity and musculoskeletal complaints in the palliative care population. Am J Hosp Palliat Care. 2000;17(1):50–58
  23. McMillen JI. A double-blind study of Parafon Forte and Flexeril(TM) in the treatment of acute skeletal muscle disorders of local origin. Curr Ther Res. 1980;28(2):164–172
  24. Miller AR. A comparative study of Parafon Forte tablets and Soma compund in the treatment of painful skeletal muscle conditions. Curr Ther Res Clin Exp. 1976;19(4):444–450
  25. Gready DM. Parafon Forte versus Robaxisal in skeletal muscle disorders: a double-blind study. Curr Ther Res Clin Exp. 1976;20(5):666–673
  26. Walker JM. Value of an acetaminophen-chlorzoxazone combination (Parafon Forte) in the treatment of acute musculoskeletal disorders. Curr Ther Res, Clin Exp. 1973;15(5):248–252
  27. Vernon WG. A double-blind evaluation of Parafon Forte in the treatment of musculo-skeletal back conditions. Curr Ther Res, Clin Exp. 1972;14(12):801–806
  28. Middleton RS. A comparison of two analgesic muscle relaxant combinations in acute back pain. Br J Clin Pract. 1984;38(3):107–109
  29. Santandrea S, Montrone F, Sarzi-Puttini P, et al.  A double-blind crossover study of two cyclobenzaprine regimens in primary fibromyalgia syndrome. J Int Med Res. 1993;21(2):74–80
  30. Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner. 1964;192:540–542
  31. Bohannon RW, Smith MB. Inter rater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther. 1987;67:206–207
  32. Sharrack B, Hughes RAC. Clinical scales for multiple sclerosis. J Neurol Sci. 1996;135:1–9
  33. Simms RW, Felson DT, Goldenberg DL. Development of preliminary criteria for response to treatment in fibromyalgia syndrome. J Rheumatol. 1991;18(10):1558–1563
  34. Mannerkorpi K, Ekdahl C. Assessment of functional limitation and disability in patients with fibromyalgia. Scand J Rheumatol. 1997;26(1):4–13
  35. Chan CH. Dantrolene sodium and hepatic injury. Neurol. 1990;40(9):1427–1432
  36. Stien R, Nordal HJ, Oftedal SI, et al.  The treatment of spasticity in multiple sclerosis: a double-blind clinical trial of a new anti-spastic drug tizanidine compared with baclofen. Acta Neurol Scand. 1987;75(3):190–194
  37. Anonymous. 2003. Methods for drug class reviews for Oregon Health Plan Practitioner-Managed Prescription Drug Plan. Oregon Evidence-based Practice Center, Portland, OR. Available at: http://www.oregonrx.org/OrgrxPDF/Skeletal%20Muscle% 20Relaxants/Revised%20EPC%20Reprt%204-9-03/ App%20C%20OHP%20Methods%202003.pdf.
  38. Harris RP, Helfand M, Woolf SH, et al.  Current methods of the third U.S. Preventive Services Task Force. Am J Prev Med. 2001;20(3S):21–35
  39. Anonymous . Undertaking systematic reviews of research on effectiveness: CRD's guidance for those carrying out or commissioning reviews CRD Report Number 4. 2nd edition. York, UK: NHS Centre for Reviews and Dissemination; 2001; Report No.: 4 (2nd edition)
  40. Mulrow CD, Oxman A. How to conduct a Cochrane systematic review. Version 3.0.2.
  41. Shakespeare DT, Boggild M, Young C. Anti-spasticity agents for multiple sclerosis. Cochrane Database of Systematic Reviews. 2001;(4):CD001332
  42. Browning R, Jackson JL, O'Malley PG. Cyclobenzaprine and back pain: a meta-analysis. Arch Intern Med. 2001;161(13):1613–1620
  43. Lataste X, Emre M, Davis C, et al.  Comparative profile of tizanidine in the management of spasticity. Neurology. 1994;44(11 Suppl 9):S53–S59
  44. Taricco M, Adone R, Pagliacci C, et al.  Pharmacological interventions for spasticity following spinal cord injury. Cochrane Database of Systematic Reviews. 2000;(2):CD001131
  45. Wallace JD. Summary of combined clinical analysis of controlled clinical trials with tizanidine. Neurology. 1994;44(11 Suppl 9):S60–S68 Discussion S68–S69
  46. Groves L, Shellenberger MK, Davis CS. Tizanidine treatment of spasticity: a meta-analysis of controlled, double-blind, comparative studies with baclofen and diazepam. Adv Ther. 1998;15(4):241–251
  47. Nibbelink DW, Strickland SC, McLean LF, et al.  Cyclobenzaprine, diazepam and placebo in the treatment of skeletal muscle spasm of local origin. Clin Ther. 1978;1(6):409–424
  48. Nogen AG. Medical treatment for spasticity in children with cerebral palsy. Child Brain. 1976;2(5):304–308
  49. Bes A, Eyssette M, Pierrot-Deseilligny E, et al.  A multi-center, double-blind trial of tizanidine, a new antispastic agent, in spasticity associated with hemiplegia. Curr Med Res Opin. 1988;10(10):709–718
  50. Nance PW. A comparison of clonidine, cyproheptadine and baclofen in spastic spinal cord injured patients. J Am Paraplegia Soc. 1994;17(3):150–156
  51. Medici M, Pebet M, Ciblis D. A double-blind, long-term study of tizanidine (‘Sirdalud’) in spasticity due to cerebrovascular lesions. Curr Med Res Opin. 1989;11(6):398–407
  52. Roussan M, Terrence C, Fromm G. Baclofen versus diazepam for the treatment of spasticity and long-term follow-up of baclofen therapy. Pharmatherapeutica. 1985;4(5):278–284
  53. Rinne UK. Tizanidine treatment of spasticity in multiple sclerosis and chronic myelopathy. Curr Ther Res Clin Exp. 1980;28(6 I):827–836
  54. Glass A, Hannah A. A comparison of dantrolene sodium and diazepam in the treatment of spasticity. Paraplegia. 1974;12(3):170–174
  55. Nance PW, Bugaresti J, Shellenberger K, et al.  Efficacy and safety of tizanidine in the treatment of spasticity in patients with spinal cord injury. North American Tizanidine Study Group. Neurology. 1994;44(11 Suppl 9):S44–S52
  56. Smolenski C, Muff S, Smolenski-Kautz S. A double-blind comparative trial of new muscle relaxant, tizanidine (DS 103-282), and baclofen in the treatment of chronic spasticity in multiple sclerosis. Curr Med Res Opin. 1981;7(6):374–383
  57. Hoogstraten MC, van der Ploeg RJ, vd Burg W, et al.  Tizanidine versus baclofen in the treatment of spasticity in multiple sclerosis patients. Acta Neurol Scand. 1988;77(3):224–230
  58. Eyssette M, Rohmer F, Serratrice G, et al.  Multi-centre, double-blind trial of a novel antispastic agent, tizanidine, in spasticity associated with multiple sclerosis. Curr Med Res Opin. 1988;10(10):699–708
  59. Newman PM, Nogues M, Newman PK, et al.  Tizanidine in the treatment of spasticity. Eur J Clin Pharmacol. 1982;23(1):31–35
  60. Bass B, Weinshenker B, Rice GP, et al.  Tizanidine versus baclofen in the treatment of spasticity in patients with multiple sclerosis. Can J Neurol Sci. 1988;15(1):15–19
  61. From A, Heltberg A. A double-blind trial with baclofen (Lioresal) and diazepam in spasticity due to multiple sclerosis. Acta Neurol Scand. 1975;51(2):158–166
  62. Schmidt RT, Lee RH, Spehlmann R. Comparison of dantrolene sodium and diazepam in the treatment of spasticity. J Neurol Neurosurg Psychiatry. 1976;39(4):350–356
  63. Cartlidge NE, Hudgson P, Weightman D. A comparison of baclofen and diazepam in the treatment of spasticity. J Neurol Sci. 1974;23(1):17–24
  64. Basmajian JV, Yucel V. Effects of a GABA-derivative (BA-34647) on spasticity. Preliminary report of a double-blind cross-over study. Am J Phys Med. 1974;53(5):223–228
  65. Basmajian JV. Lioresal (baclofen) treatment of spasticity in multiple sclerosis. Am J Phys Med. 1975;54(4):175–177
  66. Brar SP, Smith MB, Nelson LM, et al.  Evaluation of treatment protocols on minimal to moderate spasticity in multiple sclerosis. Arch Phys Med Rehab. 1991;72(3):186–189
  67. Duncan GW, Shahani BT, Young RR. An evaluation of baclofen treatment for certain symptoms in patients with spinal cord lesions. A double-blind, cross-over study. Neurology. 1976;26(5):441–446
  68. Feldman RG, Kelly-Hayes M, Conomy JP, et al.  Baclofen for spasticity in multiple sclerosis. Double blind crossover and three year study. Neurology. 1978;28(11):1094–1098
  69. Hinderer SR. The supraspinal anxiolytic effect of baclofen for spasticity reduction. Am J Phys Med Rehabil. 1990;69(5):254–258
  70. Hulme A, MacLennan WJ, Ritchie RT, et al.  Baclofen in the elderly stroke patient its side-effects and pharmacokinetics. Eur J Clin Pharmacol. 1985;29(4):467–469
  71. Jones K, Castleden CM. A double-blind comparison of quinine sulphate and placebo in muscle cramps. Age Ageing. 1983;12(2):155–158
  72. McKinlay I, Hyde E, Gordon N. Baclofen: A team approach to drug evaluation of spasticity in childhood. Scott Med J. 1980;25(SYMP):S26–S28
  73. Medaer R, Hellebuyk H, Van DBE, et al.  Treatment of spasticity due to stroke. A double-blind, cross-over trial comparing baclofen with placebo. Acta Ther. 1991;17(4):323–331
  74. Milla PJ, Jackson AD. A controlled trial of baclofen in children with cerebral palsy. J Int Med Res. 1977;5(6):398–404
  75. Orsnes G, Crone C, Krarup C, et al.  The effect of baclofen on the transmission in spinal pathways in spastic multiple sclerosis patients. Clin Neurophysiol. 2000;111(8):1372–1379
  76. Sachais BA, Logue JN, Carey MS. Baclofen, a new antispastic drug. A controlled, multicenter trial in patients with multiple sclerosis. Arch Neurol. 1977;34(7):422–428
  77. Sawa GM, Paty DW. The use of baclofen in treatment of spasticity in multiple sclerosis. Can J Neurol Sci. 1979;6(3):351–354
  78. Basmajian JV, Super GA. Dantrolene sodium in the treatment of spasticity. Arch Phys Med Rehab. 1973;54(2):61–64
  79. Chyatte SB, Birdsong JH, Roberson DL. Dantrolene sodium in athetoid cerebral palsy. Arch Phys Med Rehab. 1973;54(8):365–368
  80. Denhoff E, Feldman S, Smith MG, et al.  Treatment of spastic cerebral palsied children with sodium dantrolene. Dev Med Child Neurol. 1975;17(6):736–742
  81. Gambi D, Rossini PM, Calenda G, et al.  Dantrolene sodium in the treatment of spasticity caused by multiple sclerosis or degenerative myelopathies: A double-blind, cross-over study in comparison with placebo. Curr Ther Res. 1983;33(5):835–840
  82. Gelenberg AJ, Poskanzer DC. The effect of dantrolene sodium on spasticity in multiple sclerosis. Neurology. 1973;23(12):1313–1315
  83. Haslam RH, Walcher JR, Lietman PS, et al.  Dantrolene sodium in children with spasticity. Arch Phys Med Rehab. 1974;55(8):384–388
  84. Joynt RL, Leonard JA. Dantrolene sodium suspension in treatment of spastic cerebral palsy. Dev Med Child Neurol. 1980;22(6):755–767
  85. Katrak PH, Cole AM, Poulos CJ, et al.  Objective assessment of spasticity, strength, and function with early exhibition of dantrolene sodium after cerebrovascular accident: a randomized double-blind study. Arch Phys Med Rehab. 1992;73(1):4–9
  86. Ketel WB, Kolb ME. Long-term treatment with dantrolene sodium of stroke patients with spasticity limiting the return of function. Curr Med Res Opin. 1984;9(3):161–169
  87. Luisto M, Moller K, Nuutila A, et al.  Dantrolene sodium in chronic spasticity of varying etiology. Acta Neurol Scand. 1982;65(4):355–362
  88. Monster AW. Spasticity and the effect of dantrolene sodium. Arch Phys Med Rehab. 1974;55(8):373–383
  89. Nogen AG. Effect of dantrolene sodium on the incidence of seizures in children with spasticity. Child Brain. 1979;5(4):420–425
  90. Sheplan L, Ishmael C. Spasmolytic properties of dantrolene sodium: Clinical evaluation. Mil Med. 1975;140(1):26–29
  91. Tolosa ES, Soll RW, Loewenson RB. Treatment of spasticity in multiple sclerosis with dantrolene. JAMA. 1975;233(10):1046
  92. Weiser R, Terenty T, Hudgson P, et al.  Dantrolene sodium in the treatment of spasticity in chronic spinal cord disease. Practitioner. 1978;221(1321):123–127
  93. Knutsson E, Martensson , et al.  Antiparetic and antispastic effects induced by tizanidine in patients with spastic paresis. J Neurol Sci. 1982;53(2):187–204
  94. Lapierre Y, Bouchard S, Tansey C, et al.  Treatment of spasticity with tizanidine in multiple sclerosis. Can J Neurol Sci. 1987;14(3 Suppl):513–517
  95. Meythaler JM, Guin-Renfroe S, Johnson A, et al.  Prospective assessment of tizanidine for spasticity due to acquired brain injury. Arch Phys Med Rehab. 2001;82(9):1155–1163
  96. Smith C, Birnbaum G, Carter JL, et al.  Tizanidine treatment of spasticity caused by multiple sclerosis: results of a double-blind, placebo-controlled trial. Neurology. 1994;44(11 Suppl 9):S34–S42 Discussion S42–S43
  97. Anonymous . A double-blind, placebo-controlled trial of tizanidine in the treatment of spasticity caused by multiple sclerosis. United Kingdom Tizanidine Trial Group. Neurology. 1994;44(11 Suppl 9):S70–S78
  98. Losin S, McKean CM. Chlorzoxazone (Paraflex) in the treatment of severe spasticity. Dev Med Child Neurol. 1966;8(6):768–769
  99. Bjerre I, Blennow G. Methocarbamol in the treatment of cerebral palsy in children. Neuropadiatrie. 1971;3(2):140–146
  100. Ashby P, Burke D, Rao S, et al.  Assessment of cyclobenzaprine in the treatment of spasticity. J Neurol Neurosurg Psychiatry. 1972;35(5):599–605
  101. Brown BR, Womble J. Cyclobenzaprine in intractable pain syndromes with muscle spasm. JAMA. 1978;240(11):1151–1152
  102. Basmajian JV. Cyclobenzaprine hydrochloride effect on skeletal muscle spasm in the lumbar region and neck: two double-blind controlled clinical and laboratory studies. Arch Phys Med Rehab. 1978;59(2):58–63
  103. Bragstad A, Blikra G. Evaluation of a new skeletal muscle relaxant in the treatment of lower back pain (A Comparison of DS 103-282 with Chlorzoxazone). Curr Ther Res Clin Exp. 1979;26(1):39–43
  104. Rollings HE, Glassman JM, Soyka JP. Management of acute musculoskeletal conditions—Thoracolumbar strain or sprain: A double-blind evaluation comparing the efficacy and safety of carisoprodol with cyclobenzaprine hydrochloride. Curr Ther Res. 1983;34(6):917–928
  105. Boyles WF. Management of acute musculoskelatal conditions. Todays Ther Trends. 1983;1:1–16
  106. Scheiner JJ. Cyclobenzaprine in the treatment of local muscle spasm. Clinical evaluation of Flexeril. Minneapolis, MN: Postgraduate Medicine Communications; 1978; 39–48
  107. Aiken DW. A comparative study of the effects of cyclobenzaprine, diazepam and placebo in the treatment of acute musculoskeletal conditions of the low back. Clinical evaluation of Flexeril. Minneapolis, MN: Postgraduate Medicine Communications; 1978; 34–38
  108. Fryda-Kaurimsky Z, Muller-Fassbender H. Tizanidine (DS 103-282) in the treatment of acute paravertebral muscle spasm: a controlled trial comparing tizanidine and diazepam. J Int Med Res. 1981;9(6):501–505
  109. Hennies OL. A new skeletal muscle relaxant (DS 103-282) compared to diazepam in the treatment of muscle spasm of local origin. J Int Med Res. 1981;9(1):62–68
  110. Borenstein DG, Lacks S, Wiesel SW. Cyclobenzaprine and naproxen versus naproxen alone in the treatment of acute low back pain and muscle spasm. Clin Ther. 1990;12(2):125–131
  111. McGuinness BW. A double-blind comparison in general practice of a combination tablet containing orphenadrine citrate and paracetamol (‘Norgesic’) with paracetamol alone. J Int Med Res. 1983;11(1):42–45
  112. Salvini S, Antonelli S, De MG, et al.  Dantrolene sodium in low back pain and cervicobrachialgia treatment: A controlled study. Curr Ther Res Clin Exp. 1986;39(2):172–177
  113. Reynolds WJ, Moldofsky H, Saskin P, et al.  The effects of cyclobenzaprine on sleep physiology and symptoms in patients with fibromyalgia. J Rheumatol. 1991;18(3):452–454
  114. Bennett RM, Gatter RA, Campbell SM, et al.  A comparison of cyclobenzaprine and placebo in the management of fibrositis. A double-blind controlled study. Arthritis Rheum. 1988;31(12):1535–1542
  115. Carette S, Bell MJ, Reynolds WJ, et al.  Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia: A randomized, double-blind clinical trial. Arthritis Rheum. 1994;37(1):32–40
  116. Fogelholm R, Murros K. Tizanidine in chronic tension-type headache: a placebo controlled double-blind cross-over study. Headache. 1992;32(10):509–513
  117. Lance JW, Anthony M. Cyclobenzaprine in the treatment of chronic tension headache. Med J Aust. 1972;2(25):1409–1411
  118. Murros K, Kataja M, Hedman C, et al.  Modified-release formulation of tizanidine in chronic tension-type headache. Headache. 2000;40(8):633–637
  119. Saper JR, Lake AE, Cantrell DT, et al.  Chronic daily headache prophylaxis with tizanidine: a double-blind, placebo-controlled, multicenter outcome study. Headache. 2002;42(6):470–482
  120. Latta D, Turner E. An alternative to quinine in nocturnal leg cramps. Curr Ther Res Clin Exp. 1989;45(5):833–837
  121. Baratta RR. A double-blind comparative study of carisoprodol, propoxyphene, and placebo in the management of low back syndrome. Curr Ther Res Clin Exp. 1976;20(3):233–240
  122. Cullen AP. Carisoprodol (Soma) in acute back conditions: a double blind, randomized, placebo controlled study. Curr Ther Res Clin Exp. 1976;20(4II):557–562
  123. Hindle TH. Comparison of carisoprodol, butabarbital, and placebo in treatment of the low back syndrome. Calif Med. 1972;117(2):7–11
  124. Soyka JP, Maestripieri LR. Soma compound (carisoprodol plus phenacetin and caffeine) in the treatment of acute, painful musculoskeletal conditions. Curr Ther Res. 1979;26(2):165–180
  125. Aiken DW. Cyclobenzaprine in the treatment of acute skeletal muscle spasm of local origin. Clinical evaluation of Flexeril. Minneapolis, MN: Postgraduate Medicine Communications; 1978; 30–33
  126. Baratta RR. A double-blind study of cyclobenzaprine and placebo in the treatment of acute musculoskeletal conditions of the low back. Curr Ther Res. 1982;32(5):646–652
  127. Basmajian JV. Acute back pain and spasm. A controlled multicenter trial of combined analgesic and antispasm agents. Spine. 1989;14(4):438–439
  128. Bercel NA. Cyclobenzaprine in the treatment of skeletal muscle spasm in osteoarthritis of the cervical and lumbar spine. Curr Ther Res. 1977;22:462–468
  129. Bianchi M. Evaluation of cyclobenzaprine for skeletal muscle spasm of local origin. Clinical evaluation of Flexeril. Minneapolis, MN: Postgraduate Medicine Communications; 1978; 25–29
  130. Quimby LG, Gratwick GM, Whitney CD, et al.  A randomized trial of cyclobenzaprine for the treatment of fibromyalgia. J Rheumatol Suppl. 1989;19:140–143
  131. Steingard PM, Schildberg WL, Peterson KD. Multiclinic study of a muscle relaxant for treatment of acute musculoskeletal disorders. Osteopath Ann. 1980;8(10):44–58
  132. Valtonen EJ. A controlled clinical trial of chlormezanone, orphenadrine, orphenadrine/paracetamol and placebo in the treatment of painful skeletal muscle spasms. Ann Clin Res. 1975;7(2):85–88
  133. Dent RW, Ervin DK-. A study of metaxalone (Skelaxin) vs. placebo in acute musculoskeletal disorders: a cooperative study. 1975 Curr Ther Res. Clin Exp. 1975;18(3): 443–440
  134. Fathie K. A second look at a skeletal muscle relaxant: A double-blind study of metaxalone. Curr Ther Res. 1964;6(11):677–683
  135. Diamond S. Double-blind study of metaxalone; use as skeletal-muscle relaxant. JAMA. 1966;195(6):479–480
  136. Berry H, Hutchinson DR. A multicentre placebo-controlled study in general practice to evaluate the efficacy and safety of tizanidine in acute low-back pain. J Int Med Res. 1988;16(2):75–82
  137. Berry H, Hutchinson DR. Tizanidine and ibuprofen in acute low-back pain: results of a double-blind multicentre study in general practice. J Int Med Res. 1988;16(2):83–91
  138. Lepisto P. A comparative trial of DS 103-282 and placebo in the treatment of acute skeletal muscle spasms due to disorders of the back. Curr Ther Res. 1979;26(4):454–459
  139. Anonymous . Efficacy and gastroprotective effects of tizanidine plus diclofenac versus placebo plus diclofenac in patients with painful muscle spasms. Curr Ther Res. 1998;59(1):13–22
  140. Dapas F, Hartman SF, Martinez L, et al.  Baclofen for the treatment of acute low-back syndrome. A double-blind comparison with placebo. Spine. 1985;10(4):345–349
  141. Tisdale SAJ, Ervin DK. A controlled study of methocarbamol (Robaxin) in acute painful musculoskeletal conditions. Curr Ther Res Clin Exp. 1975;17(6):525–530
  142. Casale R. Acute low back pain. Symptomatic treatment with a muscle relaxant drug. Clin J Pain. 1988;4(2):81–88
  143. Utili R, Biotnott JK, Zimmerman HJ. Dantrolene-associated hepatic injury: incidence and character. Gastroenterol. 1977;72:610–616
  144. FDA. Accessed June 7, 2004. http://www.fda. gov/cder/foi/label/2002/21447lbl.pdf - Cached -. FDA. Available: 8/30/2002
  145. de Graaf EM, Oosterveld M, Tjabbes T, et al.  A case of tizanidine-induced hepatic injury. J Hepatol. 1996;25:772–773
  146. Rivas DA, Chancellor MB, Hill K, et al.  Neurological manifestations of baclofen withdrawal. J Urol. 1993;150(6):1903–1905
  147. Kofler M, Arturo Leis A. Prolonged seizure activity after baclofen withdrawal. Neurology. 1992;42(3 Pt 1):697–698
  148. Garabedian-Ruffalo SM, Ruffalo RL. Adverse effects secondary to baclofen withdrawal. Drug Intel Clin Pharm. 1985;19(4):304–306
  149. Kirubakaran V, Mayfield D, Rengachary S. Dyskinesia and psychosis in a patient following baclofen withdrawal. Am J Psychiatry. 1984;141(5):692–693
  150. Mandac BR, Hurvitz EA, Nelson VS. Hyperthermia associated with baclofen withdrawal and increased spasticity. Arch Phys Med Rehab. 1993;74(1):96–97
  151. Chen KS, Bullard MJ, Chien YY, et al.  Baclofen toxicity in patients with severely impaired renal function. Ann Pharmacother. 1997;31(11):1315–1320
  152. Ghose K, Holmes KM, Matthewson K. Complications of baclofen overdosage. Postgrad Med J. 1980;56(662):865–867
  153. Lipscomb DJ, Meredith TJ. Baclofen overdose. Postgrad Med J. 1980;56(652):108–109
  154. Zak R, Solomon G, Petito F, et al.  Baclofen-induced generalized nonconvulsive status epilepticus. Ann Neurol. 1994;36(1):113–114
  155. Elder NC. Abuse of skeletal muscle relaxants. Am Fam Physician. 1991;44(4):1223–1226
  156. Gaillard Y, Baillault F, Pepin G. Meprobamate overdosage: a continuing problem. Sensitive GC-MS quantitation after solid phase extraction in 19 fatal cases. Forensic Sci Int. 1997;86(3):173–180
  157. Nibbelink DW, Strickland SC. Cyclobenzaprine (Flexeril(TM)): Report of a postmarketing surveillance program. Curr Ther Res Clin Exp. 1980;28(6 I):894–903
  158. Powers BJ, Cattau EL, Zimmerman HJ. Chlorzoxazone hepatotoxic reactions. Arch Intern Med. 1986;146:1183–1186
  159. Pandyan AD, Johnson GR, Price CI, et al.  A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil. 1999;13(5):373–383
  160. Landau WM. Tizanidine and spasticity. Neurol. 1995;45(12):2295–2296

 Note: Evidence tables and appendices are available on the Web site http://www.ohppr.state.or.us/hrc/PMPD_hrc.htm#drugclass1 last updated January 2004; Web site checked on June 7, 2004 or from the authors (updated January 2004). Although the Oregon Evidence-based Practice Center receives support from the Agency for Healthcare Research and Quality (AHRQ), this report has not been reviewed or approved by AHRQ.

PII: S0885-3924(04)00215-5

doi: 10.1016/j.jpainsymman.2004.05.002

Journal of Pain and Symptom Management
Volume 28, Issue 2 , Pages 140-175 , August 2004