THE USE OF CANNABIS IN TREATING MUSCLE SPASTICITY
Evidenced Based Critical Appraisal Topic
The Use of Cannabis in Treating Muscle Spasticity
Carmen Mittleider BSN, RN, FNP-s
University of Mary
Nurs 568
THE USE OF CANNABIS IN TREATING MUSCLE SPASTICITY
Evidenced Based Critical Appraisal Topic
The Use of Cannabis in Treating Muscle Spasticity
Carmen Mittleider, BSN, RN, FNP-s
Date: March 3, 2014
Clinical Scenario
A thirty eight year old male presents to the clinic with complaints of worsening muscle spasticity
due to his Multiple Sclerosis. He has had neurology consults and has had trials of baclofen,
tizanidine, anticonvulsants, and benzodiazepines. He has not noticed much improvement with
these medications. His mother died of complications from multiple sclerosis at the young age of
forty-two. He is looking at other medication modalities for spasticity treatment.
Clinical Question
In patients diagnosed with multiple sclerosis and disabling spasticity, does the use of cannabis
improve muscle spasticity?
Articles
Corey-Bloom, J., Wolfson, T., Gamst, A., Jin, S., Marcotte, T., Bentley, H., & Gouaux, B.
(2012). Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebocontrolled trial. Canadian Medical Association Journal, 184, 1143-1150.
doi: 10.1503/cmaj.110837
Notcutt, W., Langford, R., Davies, P., Ratcliffe, S., and Potts, R. (2012). A placebocontrolled, parallel-group, randomized withdrawal study of subjects with symptoms
of spasticity due to multiple sclerosis who are receiving long-term Sativex (nabiximols).
Multiple Sclerosis Journal, 18, 219-228. doi: 10.1177/1352458511419700
Summary and Appraisal of Key Elements
Study 1
Core-Bloom, Wolfson, Gamst, Jin, Marcotte, Bentley, & Gouaux (2012), conducted a
randomized, double-blind, placebo-controlled crossover design. This study was a Level 2 level
of evidence. This study looked at adult patients with multiple sclerosis and spasticity.
Participants were recruited from a regional multiple sclerosis clinic or by referral from
specialists. Eligibility criteria were spasticity and moderate increase in tone, according to the
Ashworth scale, with score of greater or equal to 3 at the elbow, hip, or knee. Participants were
randomly assigned to either the intervention (smoked cannabis once daily for three days), or
control (identical placebo cigarettes, once daily for three days). Phase 1 was followed by an 11
day washout period, after which the participants crossed over to the opposite treatment group for
Phase 2. Thirty-seven participants were randomized at the beginning of the study, with 30
THE USE OF CANNABIS IN TREATING MUSCLE SPASTICITY
completing the trial. Strengths included two different screenings looking at medication histories,
substance abuse, psychiatric disorders, determining spasticity according to the Ashworth scale,
toxicology screening, and cognitive testing. The primary outcome was change in spasticity as
measured by the score on the Ashworth scale. The secondary outcome was assessing patients
daily for pain, physical performance, and cognitive function. Limitations involved that some
participants had previously used cannabis and may be biased to the positive effects of it. Of the
30 participants that completed the protocol, smoking cannabis reduced patient scores on the
Ashworth scale by an average of 2.74 points (95% bootstrap Cl 2.20 to 3.14) more than the
placebo (p<0.001). The order of the treatment, cannabis in Phase 1 or 2, did not significantly
affect the outcome.
Study 2
Notcutt, Langford, Davies, Ratcliffe, & Potts (2012) used a Level 2 level of evidence study to
assess spasticity in multiple sclerosis after withdrawal of Sativex, an extract of cannabis
delivered as an oromucosal spray. An enriched enrollment randomized withdrawal study design
was used. Eligible subjects with ongoing benefit from Sativex for at least twelve weeks entered
this five week placebo-controlled study. Thirty-six subjects were recruited and broken into two
groups of 18. One group received the Sativex and the other group received placebo. The
primary efficacy endpoint was the time to treatment failure (TTF), with the null hypothesis that
the TTF would be the same in subjects randomized to either the placebo or Sativex. The
secondary endpoint had a range of secondary measures assessed that included daily spasticity
severity score, daily sleep disruptions score, and Ashworth scale score, among a few others.
Limitations include the small sample size and the possibility of those in the placebo group
knowing they were not receiving the Savitex. The two groups were well matched for age,
gender, duration and type of multiple sclerosis, and disability score. Seventeen of the 36 subjects
completed the 4-week treatment period, with the other 19 withdrawing. At the end of the 4-week
study, 17 of the 18 subjects (94%) from the placebo group had failed treatment compared to 8 of
18 subjects (44%) from the Savitex group. Primary outcome was significantly in favor of
Sativex (p=0.013).
Results
The results of both studies indicated a benefit of cannabis in the treatment of muscle spasticity
with those individuals with multiple sclerosis. Study 1 showed more cognitive impact due to
smoking the cannabis compared with Study 2, in which Savitex is an oromucosal spray
derivative of cannabis. Study 1 noted a decrease in pain level with the use of cannabis. Further
studies of cannabis and/or forms of cannabis use to treat spasticity is recommended due to short
length of studies and small sample sizes.
Clinical Bottom Line
Evidence from these two studies suggests a benefit from cannabis in treating muscle spasticity,
especially for those suffering from this with multiple sclerosis. In Study 1, smoking cannabis
THE USE OF CANNABIS IN TREATING MUSCLE SPASTICITY
reduced visual analog, but did not significantly affect patient perceptions of fatigue or deficits.
Neither study had any serious adverse events during trial. Further studies would be of benefit in
determining if other forms of cannabis-oral pills, spray-would be safer with less cognitive effects
and still reduce spasticity. Also noted, that pain level had declined in Study 1 participants,
brings up questioning with cognition playing a role in this aspect. Both studies incorporated
individuals who were failing their current treatment.
Implications for Practice
After review of the above studies, I would recommend using cannabis to treat muscle spasticity.
I would add stipulations though to this. The individual would need to have noted medical trials
of other medications to treat spasticity, such as baclofen, tizanidine, benzodiazepines,
anticonvulsants. After noted failures from these medications, then the option of cannabis should
be introduced. One needs to be open to the fact of cannabis being misused and sold, along with
dependence and withdrawal effects.
THE USE OF CANNABIS IN TREATING MUSCLE SPASTICITY
References
Corey-Bloom, J., Wolfson, T., Gamst, A., Jin, S., Marcotte, T., Bentley, H., & Gouaux, B.
(2012). Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebocontrolled trial. Canadian Medical Association Journal, 184, 1143-1150.
doi: 10.1503/cmaj.110837
Notcutt, W., Langford, R., Davies, P., Ratcliffe, S., and Potts, R. (2012). A placebocontrolled, parallel-group, randomized withdrawal study of subjects with symptoms
of spasticity due to multiple sclerosis who are receiving long-term Sativex (nabiximols).
Multiple Sclerosis Journal, 18, 219-228. doi: 10.1177/1352458511419700