Pharmacological interventions for spasticity following spinal cord injury

Unique form of catheter malconnection following intrathecal baclofen surgery for spinal cord injury: a case report

This case report concerns a patient suffering from traumatic spinal cord injury with severe spasticity treated with intrathecal baclofen therapy. After revision surgery for a confirmed catheter obstruction, progressive spasticity reappeared. Diagnostics demonstrated signs of catheter fracture or disconnection adjacent to the pump. During revision surgery, the silicone layer surrounding the sutureless pump connector was shown to be curled up, revealing the cause of dysfunction. As far as we know, this form of malconnection has not been reported before. Therefore, surgeons must be aware of this complication and additional inspection of the silicone connector prior to definite connection is advised.

Spinal Cord Injury Provoked Neuropathic Pain and Spasticity, and Their GABAergic Connection

Traumatic spinal cord injury (SCI) is the devastating neurological damage to the spinal cord that becomes more complicated in the secondary phase. The secondary injury comes with inevitable long-lasting complications, such as chronic neuropathic pain (CNP) and spasticity which interfere with day to day activities of SCI patients. Mechanisms underlying CNP post-SCI are complex and remain refractory to current medical treatment. Due to the damage, extensive inhibitory, excitatory tone dysregulation causes maladaptive synaptic transmissions, further altering the nociceptive and nonnociceptive pathways. Excitotoxicity mediated GABAergic cell loss, downregulation of glutamate acid decarboxylase enzyme, upregulation of gamma-aminobutyric acid (GABA) transporters, overactivation of glutamate receptors are some of the key evidence for hypoactive inhibitory tone contributing to CNP and spasticity post-SCI. Restoring the inhibitory GABAergic tone and preventing damage-induced excitotoxicity by employing various strategies provide neuroprotective and analgesic effects. The present article will discuss CNP and spasticity post-SCI, understanding their pathophysiological mechanisms, especially GABA-glutamate-related mechanisms, therapeutic interventions targeting them, and progress regarding how regulating the excitatory-inhibitory tone may lead to more targeted treatments for these distressing complications. Taking background knowledge of GABAergic analgesia and recent advancements, we aim to highlight how far we have reached in promoting inhibitory GABAergic tone for SCI-CNP and spasticity.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

Effects of Peripheral Electromagnetic Fields on Spasticity: A Systematic Review

Electromagnetic fields are emerging as a therapeutic option for patients with spasticity. They have been applied at brain or peripheral level. The effects of electromagnetic fields applied to the brain have been extensively studied for years in spasticity, but not so at the peripheral level. Therefore, the purpose of our work is to analyze the effects of electromagnetic fields, applied peripherally to spasticity. A systematic review was conducted resulting in 10 clinical trials. The frequency ranged from 1 Hz to 150 Hz, with 25 Hz being the most commonly used and the intensity it was gradually increased but there was low homogeneity in how it was increased. Positive results on spasticity were found in 80% of the studies: improvements in stretch reflex threshold, self questionnaire about difficulties related to spasticity, clinical spasticity score, performance scale, Ashworth scale, spastic tone, Hmax/Mmax Ratio and active and passive dorsal flexion. However, results must be taken with caution due to the large heterogeneity and the small number of articles. In future studies, it would be interesting to agree on the parameters to be used, as well as the way of assessing spasticity, to be more objective in the study of their effectiveness.

Changes in spasticity following functional electrical stimulation cycling in patients with spinal cord injury: A systematic review

Spasticity is one of the most common secondary impairment after spinal cord injury (SCI). It can lead to an increase in the level of disability. The functional electrical stimulation cycling (FES-cycling) promotes recovery in patients with SCI. No systematic review has been published examining the influence of FES-cycling on the spasticity of lower extremities post-SCI.Objective: This review aimed to investigate the effects of the FES-cycling on the lower extremities spasticity in patients with SCI.Methods: PubMed, Scopus, PEDro, REHABDATA, Web of Science, and MEDLINE were searched until December 2019. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.Results: Ten studies were met the inclusion criteria. Two were randomized clinical trials, cohort study (n = 2), and pilot study (n=6). The scores on the PEDro scale ranged from one to nine, with a median score of three. The results showed evidence for the beneficial effects of FES-cycling on the spasticity of lower extremities in individuals with SCI.Conclusion: The FES-cycling intervention may reduce the lower extremities spasticity in patients with various injury levels of SCI. It is not a suitable intervention for medically unstable patients or with contraindication for lower extremities movement. Further randomized controlled trials with a large sample size strongly warranted to confirm our findings.

Efficacy of Transcutaneous Spinal Stimulation versus Whole Body Vibration for Spasticity Reduction in Persons with Spinal Cord Injury

Transcutaneous spinal stimulation (TSS) and whole-body vibration (WBV) each have a robust ability to activate spinal afferents. Both forms of stimulation have been shown to influence spasticity in persons with spinal cord injury (SCI), and may be viable non-pharmacological approaches to spasticity management. In thirty-two individuals with motor-incomplete SCI, we used a randomized crossover design to compare single-session effects of TSS versus WBV on quadriceps spasticity, as measured by the pendulum test. TSS (50 Hz, 400 μs, 15 min) was delivered in supine through a cathode placed over the thoracic spine (T11-T12) and an anode over the abdomen. WBV (50 Hz; eight 45-s bouts) was delivered with the participants standing on a vibration platform. Pendulum test first swing excursion (FSE) was measured at baseline, immediately post-intervention, and 15 and 45 min post-intervention. In the whole-group analysis, there were no between- or within-group differences of TSS and WBV in the change from baseline FSE to any post-intervention timepoints. Significant correlations between baseline FSE and change in FSE were associated with TSS at all timepoints. In the subgroup analysis, participants with more pronounced spasticity showed significant decreases in spasticity immediately post-TSS and 45 min post-TSS. TSS and WBV are feasible physical therapeutic interventions for the reduction of spasticity, with persistent effects.

Does anodal trans-cranial direct current stimulation of the damaged primary motor cortex affects wrist flexor muscle spasticity and also activity of the wrist flexor and extensor muscles in patients with stroke?: a Randomized Clinical Trial

Spasticity is a common symptom in stroke survivors. This study is double-blinded, sham-controlled randomized, clinical trial with three parallel arms. The aim of the study was to investigate the effects of anodal trans-cranial direct current stimulation (a-tDCS) over the damaged primary motor cortex (M1) on spasticity of the wrist flexor and also the activity of wrist flexor and extensor muscles in sub-acute stroke patients. This study was performed on 32 stroke patients. The patients are assigned to three groups (intervention, sham, and control). All participants in the first two groups received 20-min concurrent M1 a-tDCS or sham tDCS and functional electrical stimulation (FES) for 10 sessions (5 sessions per week), while participants in control group were given only 20-min FES for 10 sessions. Modified Ashworth scale of wrist flexors and also electromyography (EMG) activity of flexor carpi radialis (FCR) and extensor carpi radialis (ECR) were recorded before, immediately, and 1 month after the interventions. A significant reduction was shown in the MAS and EMG activity of FCR muscle at passive rest position of the wrist, immediately and 1 month after the intervention in M1 a-tDCS compared to sham and control groups (p < 0.001). Also, the EMG activity of FCR and ECR muscles during active wrist flexion and extension increased immediately and 1 month after intervention in M1 a-tDCS compared to the other groups, respectively (p < 0.001). M1 a-tDCS can significantly decrease the spasticity of wrist flexor muscle and also increase the wrist flexor and extensor muscles activity in stroke patients during active flexion and extension.

Comparison of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) for spasticity in spinal cord injury - A pilot randomized cross-over trial

OBJECTIVE

Spasticity following spinal cord injury (SCI) can impair function and affect quality of life. This study compared the effects of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) on lower limb spasticity in patients with SCI.

DESIGN

Double blind randomized crossover design.

SETTING

Neuro-rehabilitation unit, Manipal University, India.

PARTICIPANTS

Ten participants (age: 39 ± 13.6 years, C1-T11, 1-26 months post SCI) with lower limb spasticity were enrolled in this study.

INTERVENTIONS

Participants were administered electrical stimulation with TENS and FES (duration - 30 minutes) in a cross over manner separated by 24 hours.

OUTCOME MEASURES

Spasticity was measured using modified Ashworth scale (MAS) [for hip abductors, knee extensors and ankle plantar flexors] and spinal cord assessment tool for spastic reflexes (SCATS). Assessments were performed at baseline, immediately, 1 hour, 4 hours, and 24 hours post intervention.

RESULTS

A between group analysis did not show statistically significant differences between FES and TENS (P > 0.05). In the within group analyses, TENS and FES significantly reduced spasticity up to 4 hours in hip adductors and knee extensors (P < 0.01). SCATS values showed significant reductions at 1 hour (P = 0.01) following TENS and 4 hours following FES (P = 0.01).

CONCLUSION

A single session of electrical stimulation with FES and TENS appears to have similar anti-spasticity effects that last for 4 hours. The findings of this preliminary study suggest that both TENS and FES have the potential to be used as therapeutic adjuncts to relieve spasticity in the clinic. In addition, FES may have better effects on patients presenting with spastic reflexes.

Treatment patterns of in-patient spasticity medication use after traumatic spinal cord injury: a prospective cohort study

STUDY DESIGN

Prospective cohort study using the Rick Hansen SCI Registry (RHSCIR) and retrospective medical chart review.

OBJECTIVE

To describe treatment patterns of in-patient anti-spasticity medication use following traumatic spinal cord injury (SCI) in acute and rehabilitation hospital settings in British Columbia, Canada.

SETTING

Quaternary trauma center, rehabilitation center.

METHODS

Individuals with traumatic SCI between 2005 and 2014 enrolled in the Vancouver RHSCIR site (N = 917) were eligible for inclusion. Oral and injectable anti-spasticity medication use were the main outcome measures.

RESULTS

In 769 participants, higher neurological level and injury severity were associated with in-patient anti-spasticity medication use (p < 0.001 for both). Of individuals with cervical and thoracic injuries (n = 589), 37% were prescribed anti-spasticity medication during hospital admission. Baclofen was the most commonly used first line oral therapy. Mean (SD) and median time from injury to Baclofen initiation was 70 (69) and 50 days, respectively. The probability of having initiated an in-patient anti-spasticity medication was 55% (95% CI (49, 60)) for individuals 6 months post-injury, and 71% (95% CI (62, 79)) for individuals 12 months post-injury. At community discharge, the prevalence of oral and injectable anti-spasticity medication use was 26 and 5%. Practice patterns of anti-spasticity medication use (2005-2009 vs. 2010-2014) have not changed significantly over time.

CONCLUSIONS

This is the first large prospective cohort study of in-patient anti-spasticity medication use following traumatic SCI. Results from our study inform clinicians and individuals of "real world" anti-spasticity medication use among individuals with traumatic SCI and may help guide care for this population in the community.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.

The comparative study of clinical efficacy and safety of baclofen vs tolperisone in spasticity caused by spinal cord injury

In the present study we compared the clinical efficacy and safety of baclofen vs tolperisone in spasticity caused by spinal cord injury. A total of 150 patients were enrolled in the present study and were divided into two groups with 75 patients in each group, receiving baclofen or tolperisone, respectively. We used Modified Ashworth Scale, Medical research council scale, Barthel Index, and Coefficient of efficacy to measure clinical efficacy. After 6-week treatment, both groups demonstrated significant improvement in muscle tone, muscle strength and functional outcome (Group I, 1.55 ± 0.053, 2.79 ± 0.032, 59.31 ± 1.32; Group II, 1.57 ± 0.053, 3.04 ± 0.032, 73 ± 1.32 respectively). There was no significant difference regarding improvement in muscle tone and muscle strength between the two groups (Group I, 1.055 ± 0.053 vs Group II, 1.57 ± 0.053; Group I, 2.79 ± 0.032 vs Group II, 3.04 ± 0.032, p > 0.05). However, the improvement in functional outcomes was greater in group II as compared to that in group I (Group I, 59.31 ± 1.32 vs Group II, 73 ± 1.32, p < 0.05). In addition, overall efficacy coefficient was greater for group II as compared to group I (Group I, 3.6 vs Group II, 2.3, p < 0.05). Group I had more side effects compared to Group II. Compared to baclofen, tolperisone offers greater improvement in activities of daily living compared to baclofen.

Efficacy of Cerebrolysin in the reduction of spasticity during stroke rehabilitation

AIM

This study assessed the efficacy of Cerebrolysin on post-stroke spasticity, motor recovery, and global functions in an outpatient rehabilitation setting.

METHODS

In this retrospective comparison study, Cerebrolysin was administered at a daily dosage of 10 ml for over 30 days as an intramuscular injection. Control patients did not receive Cerebrolysin. All the patients participated in a standardized physical and occupational rehabilitation therapy for one month at least two times per week. Efficacy was assessed at day 30 by using the Modified Ashworth Scale (MAS) for spasticity and the Manual Muscle Testing (MMT) for motor recovery. Global function was assessed by the modified Rankin Scale (mRS) at day 30.

RESULTS

A total of 50 patients were eligible for participation according to the inclusion and exclusion criteria. Of these, 23 patients were treated with Cerebrolysin and 27 patients represented the control group. No significant group differences were observed at baseline. Patients treated with Cerebrolysin experienced a significant reduction of spasticity in muscles of the upper and lower limbs, whereas only minor changes were observed in the control group. In the Cerebrolysin group, differences were statistically significant at day 30. Significant improvements of muscle strength and global functions were observed in both groups at day 30. Cerebrolysin was safe and well tolerated.

CONCLUSION

Cerebrolysin had a beneficial effect on post-stroke spasticity in an outpatient rehabilitation setting; intramuscular treatment for over 30 days was safe and well tolerated.

Spasticity and the use of intrathecal baclofen in patients with spinal cord injury

Muscle spasms and spasticity constitute a significant problem in patients with spinal cord injury, interfering with rehabilitation and leading to impairments in quality of life in addition to medical complications. Administration of intrathecal baclofen (ITB) is indicated when spasticity continues to produce a clinical disability despite trials of oral treatments and other alternatives in patients who have functional goals and/or pain without contractures. Severe spasticity of spinal origin has been shown to respond dramatically to long-term ITB when used in appropriate patients with spasticity.

Impact of spinal cord injury on sexuality: broad-based clinical practice intervention and practical application

This study focuses on the impact a spinal cord injury may have on achieving physical and emotional intimacy, and potential to maximize sexual ability and quality of life. Spinal cord injury is a traumatic, life-altering event that is usually associated with loss of motor and sensory function, as well as sexual impairment. At the time of injury, the individual is faced with devastating loss and an abundance of new information in a setting of extreme stress and challenge. In the acute rehabilitation setting, there is often a considerable void in providing education and resources regarding sexual concerns and needs. There is a positive relationship between sexual education and sexual activity. The impact of inadequate sexual counseling and education as a part of rehabilitation can be deleterious.

A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury

Studies of spinalized animals indicate that some pharmacological agents may act on receptors in the spinal cord, helping to produce coordinated locomotor movement. Other drugs may help to ameliorate the neuropathological changes resulting from spinal cord injury (SCI), such as spasticity or demyelination, to improve walking. The purpose of this study was to systematically review the effects of pharmacological agents on gait in people with SCI. A keyword literature search of articles that evaluated the effects of drugs on walking after SCI was performed using the databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, and hand searching. Two reviewers independently evaluated each study, using the Physiotherapy Evidence Database (PEDro) tool for randomized clinical trials (RCTs), and the modified Downs & Black scale for all other studies. Results were tabulated and levels of evidence were assigned. Eleven studies met the inclusion criteria. One RCT provided Level 1 evidence that GM-1 ganglioside in combination with physical therapy improved motor scores, walking velocity, and distance better than placebo and physical therapy in persons with incomplete SCI. Multiple studies (levels of evidence 1-5) showed that clonidine and cyproheptadine may improve locomotor function and walking speed in severely impaired individuals with incomplete SCI. Gains in walking speed associated with GM-1, cyproheptadine, and clonidine are low compared to those seen with locomotor training. There was also Level 1 evidence that 4-aminopyridine and L-dopa were no better than placebo in helping to improve gait. Two Level 5 studies showed that baclofen had little to no effect on improving walking in persons with incomplete SCI. There is limited evidence that pharmacological agents tested so far would facilitate the recovery of walking after SCI. More studies are needed to better understand the effects of drugs combined with gait training on walking outcomes in people with SCI.

Modulation of resting brain cerebral blood flow by the GABA B agonist, baclofen: a longitudinal perfusion fMRI study

BACKGROUND

Preclinical studies confirm that the GABA B agonist, baclofen blocks dopamine release in the reward-responsive ventral striatum (VS) and medial prefrontal cortex, and consequently, blocks drug motivated behavior. Its mechanism in humans is unknown. Here, we used continuous arterial spin labeled (CASL) perfusion fMRI to examine baclofen's effects on blood flow in the human brain.

METHODS

Twenty-one subjects (all smokers, 12 females) were randomized to receive either baclofen (80 mg/day; N=10) or placebo (N=11). A five minute quantitative perfusion fMRI resting baseline (RB) scan was acquired at two time points; prior to the dosing regimen (Time 1) and on the last day of 21 days of drug administration (Time 2). SPM2 was employed to compare changes in RB from Time 1 to 2.

RESULTS

Baclofen diminished cerebral blood flow (CBF) in the VS and mOFC and increased it in the lateral OFC, a region involved in suppressing previously rewarded behavior. CBF in bilateral insula was also blunted by baclofen (T values ranged from -11.29 to 15.3 at p=0.001, 20 contiguous voxels). CBF at Time 2 was unchanged in placebo subjects. There were no differences between groups in side effects or cigarettes smoked per day (at either time point).

CONCLUSIONS

Baclofen's modulatory actions on regions involved in motivated behavior in humans are reflected in the resting state and provide insight into the underlying mechanism behind its potential to block drug-motivated behavior, in preclinical studies, and its putative effectiveness as an anti-craving/anti-relapse agent in humans.

Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury

Two of the most prevalent secondary complications following spinal cord injury (SCI), besides loss of function and/or sensation below the level of injury, are uncontrolled muscle spasticity and hypertensive autonomic dysreflexia. Despite the desires of the SCI community, there have been few advances in the treatment and/or management of these fundamental impediments to the quality of life associated with chronic SCI. Therefore, the purpose of this review is to focus on current drug treatment strategies that alleviate symptoms of spasticity and autonomic dysfunction. Subsequently, looking ahead, we discuss whether individuals suffering from autonomic dysreflexia and/or muscle spasms can take certain compounds that specifically and rapidly block the neurotransmission of pain into the injured spinal cord to get rapid relief for both aberrant reflexes for which painful stimuli below the level of SCI are common precipitants.

The GABA B agonist baclofen reduces cigarette consumption in a preliminary double-blind placebo-controlled smoking reduction study

The surge in dopamine in ventral striatal regions in response to drugs of abuse and drug-associated stimuli is a final common pathway of addiction processes. GABA B agonists exert their effects indirectly, by quieting dopaminergic afferents. The ability of the GABA B agonist, baclofen to ameliorate nicotine and drug motivated behavior is established within the animal literature, however its potential to do so in humans is understudied, particularly with respect to its possible utility as a smoking cessation agent. We conducted a nine-week double-blind placebo-controlled pilot trial of baclofen for smoking reduction (N=30/group) in smokers contemplating, but not quite ready to quit. Baclofen was titrated upwards to 20mg q.i.d. over a period of twelve days. The primary outcome measure was the number of cigarettes smoked per day (CPD). A significant group by time effect of medication was observed. Baclofen was superior to placebo in reducing CPD (beta=0.01, t=1.97, p<0.05). The most common side effect reported during baclofen treatment is transient drowsiness, however there were no differences between groups in mild, moderate, or severe sedation. Craving was significantly lowered at end of treatment in all smokers (p<0.02). Retention did not differ between groups. In line with a multitude of preclinical studies examining the effects of baclofen on drug-motivated behavior, baclofen reduced CPD. In agreement with other studies examining craving and drug use, reductions in CPD were accompanied by a reduction in craving, a major motivator underlying continued smoking and relapse. These preliminary results demonstrate provisional evidence of the utility of baclofen to aid in smoking cessation and indicate further investigation.

Intrathecal analgesia

Since the first use of intrathecal (IT) drug infusion systems in the early 1980s, these delivery systems have undergone numerous revisions making them more tolerable, easier to program, and longer lasting. Concurrent with technological advances, the indications for IT pump placement have also been continuously evolving, to the point where the most common indication is now noncancer pain. This article provides an evidence-based review of the indications, efficacy, and complications of IT drug therapy for the most commonly administered spinal analgesics.

Intrathecal analgesia

Since the first use of intrathecal (IT) drug infusion systems in the early 1980s, these delivery systems have undergone numerous revisions making them more tolerable, easier to program, and longer lasting. Concurrent with technological advances, the indications for IT pump placement have also been continuously evolving, to the point where the most common indication is now noncancer pain. This article provides an evidence-based review of the indications, efficacy, and complications of IT drug therapy for the most commonly administered spinal analgesics.

Donald Munro Lecture. Spinal cord injury--past, present, and future

This special report traces the path of spinal cord injury (SCI) from ancient times through the present and provides an optimistic overview of promising clinical trials and avenues of basic research. The spinal cord injuries of Lord Admiral Sir Horatio Nelson, President James A. Garfield, and General George Patton provide an interesting perspective on the evolution of the standard of care for SCI. The author details the contributions of a wide spectrum of professionals in the United States, Europe, and Australia, as well as the roles of various government and professional organizations, legislation, and overall advances in surgery, anesthesia, trauma care, imaging, pharmacology, and infection control, in the advancement of care for the individual with SCI.

Muscle Relaxants and Antispasticity Agents

Muscle relaxants make up a heterogeneous group of agents and can have a clinically significant role in the treatment of chronic muscle pain. These medications are not without possible serious side effects; hence, care should be taken in deciding on their appropriateness and ongoing monitoring performed, if prescribed.

Sexual rehabilitation of women with a spinal cord injury

STUDY DESIGN

Literature review and a qualitative study.

OBJECTIVE

This article reviews literature examining the sexual rehabilitation of women following spinal cord injury (SCI). It includes recommendations for improvements in initial clinical rehabilitation efforts and counselling services.

SETTING

United Kingdom, Denmark and Sweden.

METHODS

Articles concerning sexual rehabilitation following SCI from the last two decades have been reviewed and critiqued. Qualitative results from discussions with women with SCI in Denmark and Sweden are presented.

RESULTS

The literature focuses on the effect of neurological change on women's ability to achieve sexual arousal and orgasm. Urinary and bowel incontinence, spasticity, vaginal lubrication and autonomic dysreflexia are the physical consequences of SCI that appear to have most impact on sexual activity. More recent studies have acknowledged that psychosocial factors such as age and partnership status may also affect the successful sexual rehabilitation. Discussions with women with SCI in Denmark and Sweden on their reactions to information and counselling offered during rehabilitation revealed an overwhelming need for the exchange of information and experience with other women with SCI, and a desire for opportunities for counselling after initial rehabilitation.

CONCLUSION

Successful sexual rehabilitation of women with SCI demands a holistic approach that considers individual neurological, physical and psychosocial circumstances. Peer-counselling could make a significant contribution to the sexual rehabilitation of women with SCI.

Intrathecal baclofen pump for spasticity: an evidence-based analysis

OBJECTIVE

To conduct an evidence-based analysis of the effectiveness and cost-effectiveness of intrathecal baclofen for spasticity.

THE TECHNOLOGY

Spasticity is a motor disorder characterized by tight or stiff muscles that may interfere with voluntary muscle movements and is a problem for many patients with multiple sclerosis (MS), spinal cord injury (SCI), cerebral palsy (CP), and acquired brain injury (ABI).(1). Increased tone and spasm reduces mobility and independence, and interferes with activities of daily living, continence and sleep patterns. Spasticity may also be associated with significant pain or discomfort (e.g., due to poor fit in braces, footwear, or wheelchairs), skin breakdown, contractures, sleep disorders and difficulty in transfer. Goals of treatment are to decrease spasticity in order to improve range of motion, facilitate movement, reduce energy expenditure and reduce risk of contractures. Existing treatments include physical therapy, oral medications, injections of phenol or botulinum toxin, or surgical intervention. Baclofen is the oral drug most frequently prescribed for spasticity in cases of SCI and MS.(1) Baclofen is a muscle relaxant and antispasticity drug. In the brain, baclofen delivered orally has some supraspinal activity that may contribute to clinical side effects. The main adverse effects of oral baclofen include sedation, excessive weakness, dizziness, mental confusion, and somnolence.(2) The incidence of adverse effects is reported to range from 10% to 75%.(2) Ochs et al. estimated that approximately 25-30% of SCI and MS patients fail to respond to oral baclofen.(3;4) Adverse effects appear to be dose-related and may be minimized by initiating treatment at a low dose and gradually titrating upwards.(2) Adverse effects usually appear at doses >60 mg/day.(2) The rate of treatment discontinuation due to intolerable adverse effects has generally been reported to range from 4% to 27%.(2) When baclofen is administered orally, only a small portion of the original dose crosses the blood brain barrier and enters the central nervous system (CNS) fluid, which is the site of drug action. In order to bypass the oral route, baclofen may be administered intrathecally by infusion directly to the CNS. Candidates for intrathecal baclofen infusion are patients with spasticity who have intractable spasticity uncontrolled by drug therapy, or who experience intolerable side effects from oral baclofen. Advantages of intrathecal baclofen infusion are: Direct drug administration to the cerebrospinal fluid (CSF)The central side effects of oral baclofen, such as drowsiness or confusion, appear to be minimized with intrathecal administration.The intrathecal delivery of baclofen concentrates the drug in the CSF at higher levels than those attainable via the oral route.Intrathecal administration can use concentrations of baclofen of less than one hundredth of those used orally.(5)Adjustable/programmable continuous infusion makes it possible to finely titrate patients' doses and to vary the doses over the hours of the day. For example, the dose can be relatively low to give the patients the extensor tone needed for ambulation during the day and increased at night, thereby improving quality of sleep.Reversible (in contrast to surgery).A patient who is a candidate for intrathecal baclofen infusion must have no contraindications to the insertion of an intrathecal catheter (e.g., anticoagulant therapy, coagulopathy, local or systemic infection, anatomical abnormality of the spine).

REVIEW STRATEGY

The Medical Advisory Secretariat reviewed the literature to assess the effectiveness, safety, and cost-effectiveness of intrathecal baclofen to treat patients who have intractable spasticity uncontrolled by drug therapy, or who experience intolerable side effects to oral baclofen. The Medical Advisory Secretariat used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases.

SUMMARY OF FINDINGS

Level 2 evidence supports the effectiveness of intrathecal baclofen infusion for the short-term reduction of severe spasticity in patients who are unresponsive or cannot tolerate oral baclofenLevel 3 evidence supports the effectiveness of intrathecal baclofen for the long-term reduction of severe spasticity in patients who are unresponsive or cannot tolerate oral baclofenLevel 4 qualitative evidence demonstrates functional improvement for patients who are unresponsive or cannot tolerate oral baclofenIntrathecal baclofen is cost-effective with costs which may or may not be avoided in the Ontario health systemTrue functional use remains to be determined.

Efectividad de la gabapentina en el tratamiento de la espasticidad: estudio aleatorizado, a doble ciego y controlado con placebo

BACKGROUND AND OBJECTIVE

We aimed to demonstrate the efficacy and safety of gabapentin for the treatment of spasticity in patients with upper motor neuron syndrome.

PATIENTS AND METHOD

Thirty patients with pyramidal-tract lesions were randomized to up to 3,600 mg/day of gabapentin (n = 15) or placebo (n = 15) in a double-blind, pilot 10-week trial. The primary efficacy variable was the Ashworth Scale score. Secondary variables included the Spasm Frequency Scale, maximal range of movement, H/M Amplitude Ratio, and the Barthel Index for quality of life. Adverse events were recorded. All data were analyzed on an intent-to-treat basis.

RESULTS

Demographic and baseline characteristics were similar between the 2 treatment groups. The gabapentin group showed significant improvement in Ashworth Scale total scores, and scores for individual affected muscle groups. Fifteen of the randomized patients had spasms; the total Spasm Frequency Scale score was not significantly different between groups. Nevertheless, when affected individual muscle groups were analyzed, a significant effect of gabapentin vs placebo was observed at all visits. Gabapentin did not modify the scores of the range of movement, the H/M Amplitude Ratio, or the Barthel Index tests. No gait or displacement impairment were seen during treatment with gabapentin. Related adverse events occurred less frequently in the gabapentin group, and fewer gabapentin patients withdrew because of adverse events.

CONCLUSIONS

Gabapentin demonstrated efficacy and safety at doses between 2,700 and 3,600 mg/day as a therapy for the spasticity associated with the upper motor neuron syndrome.

Drug effects on salivary glands: dry mouth

OBJECTIVE

To identify drugs associated with the complaint of dry mouth.

MATERIALS AND METHODS

MEDLINE was searched for papers 1980-2002 using keywords, oral, mouth, salivary, drugs, dry mouth and xerostomia, and relevant secondary references were hand-searched.

RESULTS

Evidence was forthcoming for a number of xerogenic drugs, especially antimuscarinic agents, some sympathomimetic agents, and agents affecting serotonin and noradrenaline uptake, as well as a miscellany of other drugs such as appetite suppressants, protease inhibitors and cytokines.

CONCLUSION

Dry mouth has a variety of possible causes but drugs--especially those with anticholinergic activity against the M3 muscarinic receptor--are the most common cause of reduced salivation.

Ventral tegmental area region governs GABA(B) receptor modulation of ethanol-stimulated activity in mice

Locomotor stimulation in response to ethanol in mice may model human ethanol-induced euphoria. The associated neural substrates, possibly relevant to alcoholism, have not been fully elucidated. Systemic injection of baclofen, a GABA(B) receptor agonist, attenuates ethanol's stimulant effects. GABA(B) receptors on dopamine cell bodies in the ventral tegmental area (VTA) may modulate ethanol-induced dopamine release, a postulated mechanism for ethanol's stimulant effects. However, baclofen's attenuating effects could be associated with peripheral receptor actions. Baclofen was injected i.c.v. or into the VTA of FAST mice, bred for extreme sensitivity to ethanol-induced locomotor stimulation, to test the hypotheses that (1) central GABA(B) receptors influence baclofen's effects on ethanol-stimulated activity, and (2) VTA GABA(B) receptors specifically modulate ethanol's stimulant effects. I.c.v. baclofen dose-dependently attenuated ethanol stimulation, supporting a central locus for baclofen's effects. Anterior VTA baclofen also attenuated ethanol stimulation. However, more posterior VTA infusions unexpectedly potentiated ethanol stimulation. In SLOW mice, bred for resistance to ethanol stimulation, posterior intra-VTA baclofen did not alter EtOH response. However, anterior VTA baclofen alone produced a locomotor depressant effect in SLOW mice, not seen in FAST mice. GABA(B) receptor autoradiography using [(3)H]CGP 54626, a potent GABA(B) receptor antagonist, did not reveal line differences in binding density in the VTA, or in the substantia nigra pars compacta, a nearby brain structure associated with motor control. These results suggest that anterior VTA GABA(B) receptors play a role in baclofen's attenuation of ethanol's stimulant effects, and that posterior VTA GABA(B) receptors serve an opposite role that is normally masked. Selection for differential ethanol stimulant sensitivity has altered VTA GABA(B) systems that influence locomotor behavior. However, differences in GABA(B) receptor densities in the VTA or substantia nigra pars compacta cannot explain the selected line difference.

The medical management of spasticity

When spasticity produces a clinical disability by interfering with posture, motor capacity, nursing or daily living activities, medical treatment is recommended. It is mainly indicated when the muscle overactivity is diffusely distributed and should be implemented early, to prevent permanent musculoskeletal deformities or contractures. A pharmacological approach relies on the use of drugs which modulate neurotransmitters acting at the cortico-spinal level (GABA, glycine, glutamate, noradrenaline, serotonin). The aim of this treatment is to decrease spinal reflex excitability by reducing the release of excitatory neurotransmitters, or by potentiating the activity of inhibitory inputs. Evaluation of the efficacy of these drugs is determined by the therapeutic objectives which may be biomechanical, or functional. Diazepam increases presynaptic inhibition by stimulating GABA(A) receptors in the brainstem and spinal cord. In double-blind studies of patients with spinal cord lesions, antispastic efficacy has been shown, but side-effects are common. Baclofen stimulates GABA(B) receptors inducing a suppression of excitatory neurotransmitter release. Antispastic efficacy is sufficiently documented, but no definite effects on ambulation or activities of daily living have been proved. Tizanidine has an alpha2-agonist activity (at spinal and supraspinal level) and decreases the presynaptic activity of excitatory interneurones. The main clinical effects are a reduction in tonic stretch, polysynaptic reflexes, and co-contraction, with fewer side-effects but no definite functional change. The efficacy of several other antispastic drugs is documented in a few controlled studies, but the majority of information arises from open trials or anecdotal observations.