Manejo no farmacológico la espasticidad en la Esclerosis Múltiple y Neuroestimulación en Parkinson

En ésta entrada de domingo os dejo dos artículos relacionados con la Neurorrehabilitación.  Simplemente os dejo un pequeño comentario y a continuación podéis os he añadido directamente el abstract y la referencia del artículo.

1) Se ha publicado una actualización de la Cochrane sobre las intervenciones no farmacológicas en la espasticidad en pacientes con Esclerosis Múltiple. Se han encontrado pruebas de baja calidad a favor de la terapia física en conjunción con otras intervenciones (p.ej toxina botulínica) y a favor de la estimulación magnética y terapia electromagnética.

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Amatya B, Khan F, La Mantia L, Demetrios M, Wade DT.
Non pharmacological interventions for spasticity in multiple sclerosis.
Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD009974. DOI: 10.1002/14651858.CD009974.pub2.BackgroundSpasticity is commonly experienced by people with multiple sclerosis (MS), and it contributes to overall disability in this population. A wide range of non pharmacological interventions are used in isolation or with pharmacological agents to treat spasticity in MS. Evidence for their effectiveness is yet to be determined.


To assess the effectiveness of various non pharmacological interventions for the treatment of spasticity in adults with MS.

Search methods

A literature search was performed using the Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group on using the Cochrane MS Group Trials Register which among other sources, contains CENTRAL, Medline, EMBASE, CINAHL, LILACS, PEDRO in June 2012. Manual searching in the relevant journals and screening of the reference lists of identified studies and reviews were carried out. Abstracts published in proceedings of conferences were also scrutinised.

Selection criteria

Randomised controlled trials (RCTs) that reported non pharmacological intervention/s for treatment of spasticity in adults with MS and 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; interventions given in different settings), were included.

Data collection and analysis

Three review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool for best-evidence synthesis. A meta-analysis was not possible due to methodological, clinical and statistical heterogeneity of included studies.

Main results

Nine RCTs (N = 341 participants, 301 included in analyses) investigated various types and intensities of non pharmacological interventions for treating spasticity in adults with MS. These interventions included: 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). All studies scored ‘low’ on the methodological quality assessment implying high risk of bias.

There is ‘low level’ evidence for physical activity programmes used in isolation or in combination with other interventions (pharmacological or non pharmacological), and for repetitive magnetic stimulation (iTBS/rTMS) with or without adjuvant exercise therapy in improving spasticity in adults with MS. No evidence of benefit exists to support the use of TENS, sports climbing and vibration therapy for treating spasticity in this population.

Authors’ conclusions

There is ‘low level’ evidence for non pharmacological interventions such as physical activities given in conjunction with other interventions, and for magnetic stimulation and electromagnetic therapies for beneficial effects on spasticity outcomes in people with MS. A wide range of non pharmacological interventions are used for the treatment of spasticity in MS, but more robust trials are needed to build evidence about these interventions.

Neuroestimulación en Parkinson
La Neuroestimulación subtalácmica en Pacientes con Parkinson y alteraciones motoras precoces fue superior al tratamiento médico con respecto a la discapacidad motora, actividades de la vida diaria, las complicaciones inducidas por levodopa, y el tiempo con buena movilidad y sin discinesia.

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Neurostimulation for Parkinson’s Disease with Early Motor Complications
W.M.M. Schuepbach, J. Rau, K. Knudsen, J. Volkmann, P. Krack, L. Timmermann, T.D. Hälbig, H. Hesekamp, S.M. Navarro, N. Meier, D. Falk, M. Mehdorn, S. Paschen, M. Maarouf, M.T. Barbe, G.R. Fink, A. Kupsch, D. Gruber, G.-H. Schneider, E. Seigneuret, A. Kistner, P. Chaynes, F. Ory-Magne, C. Brefel Courbon, J. Vesper, A. Schnitzler, L. Wojtecki, J.-L. Houeto, B. Bataille, D. Maltête, P. Damier, S. Raoul, F. Sixel-Doering, D. Hellwig, A. Gharabaghi, R. Krüger, M.O. Pinsker, F. Amtage, J.-M. Régis, T. Witjas, S. Thobois, P. Mertens, M. Kloss, A. Hartmann, W.H. Oertel, B. Post, H. Speelman, Y. Agid, C. Schade-Brittinger, and G. Deuschl for the EARLYSTIM Study Group
N Engl J Med 2013; 368:610-622February 14, 2013DOI: 10.1056/NEJMoa1205158

Subthalamic stimulation reduces motor disability and improves quality of life in patients with advanced Parkinson’s disease who have severe levodopa-induced motor complications. We hypothesized that neurostimulation would be beneficial at an earlier stage of Parkinson’s disease.

In this 2-year trial, we randomly assigned 251 patients with Parkinson’s disease and early motor complications (mean age, 52 years; mean duration of disease, 7.5 years) to undergo neurostimulation plus medical therapy or medical therapy alone. The primary end point was quality of life, as assessed with the use of the Parkinson’s Disease Questionnaire (PDQ-39) summary index (with scores ranging from 0 to 100 and higher scores indicating worse function). Major secondary outcomes included parkinsonian motor disability, activities of daily living, levodopa-induced motor complications (as assessed with the use of the Unified Parkinson’s Disease Rating Scale, parts III, II, and IV, respectively), and time with good mobility and no dyskinesia.

For the primary outcome of quality of life, the mean score for the neurostimulation group improved by 7.8 points, and that for the medical-therapy group worsened by 0.2 points (between-group difference in mean change from baseline to 2 years, 8.0 points; P=0.002). Neurostimulation was superior to medical therapy with respect to motor disability (P<0.001), activities of daily living (P<0.001), levodopa-induced motor complications (P<0.001), and time with good mobility and no dyskinesia (P=0.01). Serious adverse events occurred in 54.8% of the patients in the neurostimulation group and in 44.1% of those in the medical-therapy group. Serious adverse events related to surgical implantation or the neurostimulation device occurred in 17.7% of patients. An expert panel confirmed that medical therapy was consistent with practice guidelines for 96.8% of the patients in the neurostimulation group and for 94.5% of those in the medical-therapy group.

Subthalamic stimulation was superior to medical therapy in patients with Parkinson’s disease and early motor complications. (Funded by the German Ministry of Research and others; EARLYSTIM number, NCT00354133.)

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