A Clinical Study of Intrathecal Baclofen Using a Programmable Pump for Intractable Spasticity

Characteristics of Changes in Intrathecal Baclofen Dosage over Time due to Causative Disease

Intrathecal baclofen (ITB) therapy effectively treats spasticity caused by brain or spinal cord lesions. However, only a few studies compare the course of treatment for different diseases. We investigated the change in daily dose of baclofen per year and its associated adverse events in patients presenting with the three most common etiologies at our institute: hereditary spastic paraplegia, cerebral palsy, and spinal cord injury. The ITB pumps were implanted from July 2007 to August 2019, with a mean follow-up period of 70 months. In patients with hereditary spastic paraplegia, baclofen dosage was reduced after eight years following ITB introduction, and the treatment was terminated in one patient owing to disease progression. In patients with cerebral palsy, the dosage increased gradually, and became constant in the 11th year. Patients with spinal cord injury gradually increased their baclofen dosage throughout the entire observation period. Severity and adverse event rates were higher in patients with cerebral palsy than in others. The degree and progression of spasticity varied depending on the causative disease. Understanding the characteristics and natural history of each disease is important when continuing ITB treatment.

Intrathecal Baclofen Monotherapy and Polyanalgesia for Treating Chronic Pain in Patients with Severe Spasticity

PURPOSE OF REVIEW

Intrathecal drug delivery is a well evidenced strategy for the treatment of many chronic pain syndromes. While opioids, anesthetics, and ziconotide are the most commonly used agents, intrathecal baclofen (ITB), which is indicated to treat spasticity, is also thought to have some analgesic properties that are poorly understood. These analgesic benefits have been reported with ITB use in treating patients with central neurological disorders who suffer from severe spasticity and chronic pain. Our review aims to characterize ITB's effects on pain, function, and quality of life in patients with severe spasticity. We performed a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The primary outcome parameters were analgesic relief and functional improvements. Secondarily, quality of life and adverse effects were also recorded.

RECENT FINDINGS

After an initial survey identified 393 studies, 20 studies met final inclusion criteria. Of these, 16 utilized ITB monotherapy and 4 utilized ITB polyanalgesia. Overall, there was a paucity of high-powered studies. Mean titrated ITB doses ranged from 140 to 627.9 μg daily. Nineteen studies reported improved pain and spasticity. Seven studies reported improved functional outcomes and quality of life. Our results show that ITB may be an effective agent in treatingfor the treatment of chronic pain in patients with severe spasticity independent of its spasmolytic effects. Although this evidence was largely derived from studies lacking clearly defined outcomes of pain relief, ITB is reasonable to consider for concurrent spasticity and pain management. Well-designed studies are still needed to characterize ITB's analgesic efficacy when used in patients with severe spasticity.

Evaluation of the cognitive benefits of intrathecal baclofen pump implantation in people with intractable multiple sclerosis related spasticity

BACKGROUND

Spasticity is a common problematic symptom in Multiple Sclerosis with over one third of patients failing first line therapies. Intrathecal baclofen is a safe and efficacious option for treatment resistant spasticity. Anecdotally patients report improved concentration/cognitive performance when switching to intrathecal baclofen (ITB) from systemic medications.

AIM

To explore whether subjects who proceed with ITB pump implantation for spasticity management and reduce oral anti-spasticity agents will have improved cognitive function.

METHODS

Subjects were admitted for trial of ITB via lumbar puncture and subsequent pump implantation. Spasticity and cognitive measures before ITB trial and 3 months post implant were recorded. Paired t-test or Wilcoxon Signed Ranks test was used for within subject change and effect sizes (Cohen's d_z) were calculated. Subgroup analysis of those on ≥2, or ≤ 1 spasticity medications at baseline was performed.

RESULTS

27 subjects with MS completed per protocol. Mean age 46 years [26 - 56], disease duration 15 years [6 - 26], RRMS = 3, SPMS = 17 and PPMS=7. The majority were on multiple spasticity medications. Spasticity scores significantly improved post pump implant. Mean ITB dose at 3 months was 143 mcg / day and 19 discontinued all other treatments for spasticity. There was no deterioration on any cognitive or mood measure. An improvement of moderate effect size was found in Backwards Digit Span (d=0.41, p=0.059) and HADS - anxiety (d=0.37, p=0.097). Fatigue Severity Scale score decreased substantially (d=0.81, p=0.005). Small improvements in Symbol Digit Modalities Test score (d=0.24) and Sustained Attention to Response Task response time (d=0.23) were non-significant. Performance on other measures did not change. Effect sizes were larger in subgroup on ≥2 oral spasticity medications at baseline, compared to the group on ≤1 medication (SDMT, d=0.42 vs d=0.07; Backwards digit span 0.45 vs 0.28; HADS-anxiety 0.39 vs 0.32; HADS-depression d=0.32 vs 0.05 and FSS, d= 1.14 vs 0.42).

CONCLUSIONS

In a pilot study exploring the impact of ITB on cognition, spasticity scores improved universally and beneficial effects on some measures of fatigue, anxiety, auditory attention and verbal working memory were found. Improvement of speed of processing in those withdrawing higher doses of oral medication was also demonstrated suggesting that switching to ITB has added cognitive and psychological benefits for people with MS.

Covalent organic framework membrane for size selective release of small molecules and peptide in vitro

The ability to control small drug release is crucial in biomedicine, especially for inhibiting the side effects of drugs, but it is still challenging. Herein, to mimic the controlled release of drugs, the release of organic molecules, e.g., small organic dyes and peptides, through Covalent Organic Framework (COF) membranes with ordered nanoscale pores has been investigated, showing constant zero-order release behaviours. Meanwhile, biological assessments show the good biocompatibility of the COF membrane-based release system, and the high stability of the COF membrane was manifested by the long-term release of small molecules in aqueous media.

Efficiency and Safety of Aftercare With Intrathecal Baclofen on Location

OBJECTIVES

Patients with intractable spasticity treated with intrathecal baclofen (ITB) need regular evaluation and aftercare in an outpatient clinic or pain clinic setting. Logistically, this can be challenging. A solution could be to perform treatment at the patient's home setting. In the Netherlands, a project of the Dutch Healthcare Authority was initiated to deliver ambulatory ITB-related services via a home-based Ambulant Care Clinic. This aftercare is performed by nurse practitioners (NP) with support from a medical specialist. The scope of the study was to investigate the efficiency and safety of ITB-care for patients with severe disabling spasticity in their home setting.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data. Patients with congenital or acquired spasticity were treated with ITB (1st April 2011 to January 1st 2016) using an implanted programmable pump system were referred to the home-based Ambulant Care Clinic by various neuromodulation centers in the Netherlands. All study parameters were a part of the standard intake and follow-up documentation.

RESULTS

Of the 900 patients treated with ITB in the Netherlands, 239 were referred to the home-based Ambulant Care Clinic and included in this study. Mean age was 45.5 (range 7-82) years; 52% lived at home; the average satisfaction score was 9 (scale 0-10); and 0.29% had (serious) adverse events (60% of clinical manifestations were prevented by remote double-check control). Certifications for patient safety and quality standards were obtained.

CONCLUSIONS

The concept of ITB aftercare on location demonstrated efficacy and safety in the described setting. For troubleshooting, close collaboration with a neuromodulation center is necessary and can be arranged in chain-based care.

Eleven years' experience with Intrathecal Baclofen - Complications, risk factors

OBJECTIVE

Treatment with intrathecal baclofen (ITB) is commonly used in patients with severe spasticity. However, complications may occur after implantation of the ITB-device, albeit mainly procedure- and device-related problems. The aim of the study was to assess surgical- as well as catheter- and pump-related complications and define their risk factors.

METHODS

We retrospectively evaluated all patients with an implanted ITB-device who were treated at the Department of Neurology, Hochzirl Hospital, Zirl, Austria, between 2006 and 2016.

RESULTS

Twenty-nine of 116 (25%) patients experienced 32 complications: 5 procedure- and 27 device-related (4 pump- and 23 catheter-associated) problems occurred. Risk factors for sustaining any complication were a spinal localization of lesion (odds ratio [OR] OR 2.71, p = .021), other catheter types than an Ascenda^® catheter (OR 3.87, p = .041), a lower modified Rankin Scale (median 4 vs. 5; OR 2.86, p = .015) and a higher Barthel Index (median 53 vs. 0; OR 2.84, p = .006). The median time from the last ITB-related surgery to the first complication was 18 (IQR 1-57) months. Overall, 47% complications occurred within the first year after any surgical procedure regarding the ITB-device, thereof 25% within the first month.

CONCLUSIONS

Procedure- and device-related complications are frequent after implantation of an ITB-device with catheter-associated complications as the most frequently encountered problems. Patients with a spinal origin of spasticity, a lower modified Rankin Scale and a higher Barthel Index have a higher risk to sustain a complication.

Intrathecal baclofen therapy in children: an analysis of individualized goals

AIM

To determine whether intrathecal baclofen (ITB) therapy improves performance and performance satisfaction in goal areas identified by patients' parents.

METHOD

This study formed part of an ongoing multicentre national audit involving six paediatric ITB pump implant centres across Australia. The Canadian Occupational Performance Measure was the primary outcome measure utilized at baseline, 6 months, and 12 months after pump implants in paediatric patients receiving ITB therapy for the first time between 31st December 2009 and 31st December 2014.

RESULTS

Twenty-five children had goals identified (mean age 11y 1mo), 19 had a diagnosis of cerebral palsy and 22 were at Gross Motor Function Classification System level IV, V, or equivalent. Strong evidence for an improvement in goal performance (2.33, 95% CI 1.70, 2.96, p<0.001) and performance satisfaction scores (3.08, 95% CI 2.28, 3.88, p<0.001) were demonstrated at 6 months, compared to baseline. The differences were clinically significant and were sustained to 12 months.

INTERPRETATION

ITB therapy in paediatric patients with hypertonia results in clinically significant improvements in average performance and performance satisfaction scores.

WHAT THIS PAPER ADDS

The most commonly identified goals of parents of children treated with intrathecal (ITB) therapy were: improving ease of dressing, positioning, and transfers. ITB therapy is effective in improving performance and performance satisfaction in children with hypertonia. Score improvements are mainly evident within the first 6 months of therapy.

The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care

The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.

Current and Future Issues in the Development of Spinal Agents for the Management of Pain

Targeting analgesic drugs for spinal delivery reflects the fact that while the conscious experience of pain is mediated supraspinally, input initiated by high intensity stimuli, tissue injury and/or nerve injury is encoded at the level of the spinal dorsal horn and this output informs the brain as to the peripheral environment. This encoding process is subject to strong upregulation resulting in hyperesthetic states and downregulation reducing the ongoing processing of nociceptive stimuli reversing the hyperesthesia and pain processing. The present review addresses the biology of spinal nociceptive processing as relevant to the effects of intrathecally-delivered drugs in altering pain processing following acute stimulation, tissue inflammation/injury and nerve injury. The review covers i) the major classes of spinal agents currently employed as intrathecal analgesics (opioid agonists, alpha 2 agonists; sodium channel blockers; calcium channel blockers; NMDA blockers; GABA A/B agonists; COX inhibitors; ii) ongoing developments in the pharmacology of spinal therapeutics focusing on less studied agents/targets (cholinesterase inhibition; Adenosine agonists; iii) novel intrathecal targeting methodologies including gene-based approaches (viral vectors, plasmids, interfering RNAs); antisense, and toxins (botulinum toxins; resniferatoxin, substance P Saporin); and iv) issues relevant to intrathecal drug delivery (neuraxial drug distribution), infusate delivery profile, drug dosing, formulation and principals involved in the preclinical evaluation of intrathecal drug safety.

Intrathecal baclofen therapy for spasticity: A compliance-based study to indicate effectiveness

Background:

Intrathecal baclofen (ITB) therapy using a programmable battery-based pump is a well-recognized option in the treatment of patients with refractory spasticity. Improvements in clinical scale scores for muscle spasticity among this heterogeneous group of patients may not reflect the functional benefits of this therapeutic option. The aim of our study is to report the efficacy of ITB therapy by setting the patient's compliance at the 2-year follow-up after pump implantation as an indicator of treatment efficacy, as appreciated by the patients or their caregivers.

Methods:

A cohort of 31 patients admitted for ITB therapy was studied. Treatment and follow-up expenses were supported by national health services. Compliance to follow-up visits 2 years after implantation was used as an indicator of treatment efficacy.

Results:

Twenty-seven patients (mean age: 28.8 ± 19.3 years) were included in the study. At the 2-year post-implantation set point, 20 patients continued to comply with the treatment program. Those 20 patients reported at least moderate improvements in their symptoms, which justified treatment compliance.

Conclusion:

At the 2-year follow-up post-implantation set point, nearly 3 of 4 patients (74.1%) continued to comply with the treatment, indicating treatment efficacy.

The effect of intrathecal baclofen treatment on activities of daily life in children and young adults with cerebral palsy and progressive neurological disorders

INTRODUCTION

Intrathecal baclofen (ITB) treatment is applied in patients with spastic cerebral palsy (SCP), dystonic cerebral palsy (DCP) and progressive neurological disease (PND). Our aim was to investigate whether ITB treatment has a different effect on activities of daily life (ADL) in these groups.

METHOD

A retrospective and cross-sectional survey was conducted using a questionnaire to assess the qualitative effect of ITB (Likert scale) on different domains of functioning (mobility, personal care, communication, comfort) and satisfaction with the results. Groups were compared using non-parametric statistics.

RESULTS

Questionnaires were completed for 68 patients (39 SCP, 13 DCP, 16 PND). Satisfaction scores were relatively high in all groups (7-8) and the positive effect on personal care and communication was similar in all groups. The PND group had the shortest follow-up and scored significantly less favourably for the effect on mobility and comfort.

DISCUSSION

This is the first study to show that ITB treatment has similar effects on personal care and communication in stable and progressive neurological disease. The decrease in mobility in the PND group is likely due to the progressive nature of the disease. The different effect on comfort between groups is mainly due to the smaller effect on startles in the PND group.

Standing up in multiple sclerosis (SUMS): protocol for a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of a home-based self-management standing frame programme in people with progressive multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15 years of diagnosis, approximately 50 % of affected people are unable to walk unaided, and over time an estimated 25 % depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people's homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option.

METHODS/DESIGN

SUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30 min three times weekly over 20 weeks. Each participant will be followed-up at 20 and 36 weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health-related quality of life. An embedded qualitative component will explore participant's and carer's experiences of the standing programme.

DISCUSSION

This is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom.

TRIAL REGISTRATION

ISRCTN69614598 DATE OF REGISTRATION: 3.2.16 (retrospectively registered).

Cost-effectiveness of Intrathecal Baclofen Therapy in severe refractory non-focal disabling spasticity: a Spanish hospital perspective

BACKGROUND

Current knowledge about long-term economic consequences of Intrathecal Baclofen Therapy (ITB Therapy®) is incomplete.

METHODS

A markov model was developed to estimate long-term clinical and economic outcomes with ITB Therapy® and conventional medical management of severe refractory non-focal disabling spasticity. Clinical and cost inputs were obtained through a non-interventional, prospective, observational study in a Spanish neurorehabilitation hospital.

RESULTS

ITB Therapy® increased remaining lifetime costs by €35,605 and resulted in a gain of 1.06 quality-adjusted life-years (QALYs), thus showing an incremental cost-effectiveness ratio (ICER) of €33,619/QALY gained. In alternative scenarios, reflecting other clinical settings and management options, considerably lower ICER values were obtained. In particular, opportunities were identified to improve efficiency by setting clinically and economically sound targets for post-operation length of stay.

CONCLUSION

In the Spanish setting, ITB Therapy® resulted in an ICER close to €30,000/QALY gained; potential ways to reduce costs and further enhance efficiency can be identified.

Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report

BACKGROUND

Whenever oral treatment or botulinum toxin injections fail to control severe spasticity, a trial with intrathecal baclofen is recommended no earlier than 1 year after brain injury. When irreversible contractures are to be avoided, such a trial might be done earlier. Some have briefly reported cognitive modifications with this treatment.

METHODS

During the trial period, intrathecal baclofen is continuously infused by a portable external pump through an intrathecal catheter. The daily dose is adjusted according to the clinical response. If the expected response is obtained by reduction of spasticity, a programmable pump is then implanted. Throughout the procedure, close neuropsychological follow-up is pursued.

RESULTS

Two persons with extremely severe brain injury and spasticity received a programmable pump less than 10 months after trauma. Unexpectedly, one emerged from the minimally conscious state and the other from post-traumatic amnesia.

CONCLUSIONS

Intrathecal baclofen should be considered within the first year after brain injury whenever spasticity does not respond to medication. ITB lessens the degree of spasticity which in turn facilitates care and, thus, has the potential to limit contractures. After severe brain injury, this treatment might trigger recovery from altered states of consciousness, improve cognition and facilitate rehabilitation.

Evaluation of functional goal outcomes using the Canadian Occupational Performance Measure (COPM) following Deep Brain Stimulation (DBS) in childhood dystonia

PURPOSE

To evaluate the functional goal-directed outcomes of Deep Brain Stimulation (DBS) in childhood dystonia according to aetiology and to explore relationship with a traditional impairment-based measure.

METHOD

This is a prospective case series study involving thirty children with dystonia with a 1-year follow-up post-DBS. The Canadian Occupational Performance Measure (COPM) and Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) were used as primary outcome measures. Results were analysed based on aetiology in 3 groups: 1. primary/primary plus dystonia; 2. secondary dystonia-cerebral palsy (CP); 3. secondary dystonia-non-CP group. Correlation between functional outcome using COPM and dystonia improvement as captured by BFMDRS was measured.

RESULTS

All groups demonstrated significant improvement in individualised goal attainment, measured with the COPM, at 1-year post-DBS. The secondary dystonia-CP group also achieved significant improvement at 6 months for performance and satisfaction scores. In the majority of secondary dystonias, the BFMDRS failed to demonstrate significant improvement. A linear correlation between change in BFMDRS and COPM scores was observed when the entire cohort was analysed.

INTERPRETATION/CONCLUSIONS

DBS improved functional performance, independently of the dystonic phenotype. Improvements in individualized COPM functional goal areas were seen in the absence of significant changes in BFMDRS scores, highlighting the relative insensitivity of impairment scales in this patient group.

Change in parent-identified goals in young children with cerebral palsy receiving a context-focused intervention: associations with child, goal and intervention factors

The purpose of this study was to examine the relationship between goal achievement measured by the Canadian Occupational Performance Measure (COPM) and child, goal, and intervention factors. Participants were 41 preschool children with cerebral palsy (CP) who were in the context-focused therapy arm of a randomized controlled trial. Factors including child age, Gross Motor Function Classification System (GMFCS) level, type and complexity of goals, and intervention strategies were analyzed. Children made large, positive mean changes on the COPM over 6 months (Performance = 3.8, SD = 1.9; Satisfaction = 4.3, SD 4.3) with younger children showing greater change. The COPM scores had low to moderate correlations with change on the Pediatric Evaluation of Disability Inventory and the Gross Motor Function Measure (GMFM-66). Regression analysis indicated that age, but not GMFCS level influenced COPM change scores. Goal complexity and intervention strategies were not significantly related to COPM change scores. The results provide support for using the COPM as an individualized measure of change in young children with CP receiving intervention.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults

OBJECTIVE

To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors.

DESIGN

A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010.

SETTING

A neurologic rehabilitation department in a university hospital.

PARTICIPANTS

All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Frequency and type of AEs.

RESULTS

In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death.

CONCLUSIONS

The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

Evaluation of usefulness of scintigraphic imaging in diagnosis of intrathecal drug delivery system malfunction - a preliminary report

BACKGROUND

Implantable intrathecal drug delivery systems (IDDS) are basic tool enabling chronic intrathecal pharmacotherapy. Lack of expected clinical results of IDDS therapy necessitates search for the cause with the help of diagnostic imaging methods among other things. Beside radiological techniques, it is also possible to visually assess IDDS systems by nuclear medicine methods. In this study we assess utility of radioisotopic methods in differential diagnosis of failure of therapy with IDDS systems.

MATERIAL/METHODS

Scintigraphic studies were performed in selected patients with neurological diseases associated with spasticity, who had IDDS system implanted and were unable to maintain satisfying clinical effect of inrathecally infused baclofen. After emptying the IDDS system of the drug, radiotracer (99mTc-DTPA) solution was injected into the pump reservoir. Subsequently, a series of scintigraphic images was registered, demonstrating passage and distribution of the infused radiotracer.

RESULTS

In all investigated cases, scintigraphic study resulted in acquiring relevant additional diagnostic information. Normal or disrupted distribution of radiotracer in spinal canal allowed for a diagnosis drug resistance or demonstrated presence of arachnoid adhesions respectively. Early appearance of radiotracer in blood was considered a proof of leak. Our examinations had decisive influence on further patient treatment, allowing for diagnosis of drug resistance in one patient or complication related to IDDS system in three other cases including breakage of a catheter, pump malfunction and arachnoid adhesions.

CONCLUSIONS

Scintigraphic methods carry significant amount of information facilitating final diagnosis of the cause of IDDS therapy failure. They should become an important element complementing the diagnostic strategy in patients with suspected failure of intrathecal drug administration systems. Interpretation of radioisotopic studies, since they are purely functional, must be performed in strict relation to clinical data and radiological examinations as they carry indispensable, basic information regarding morphology.

Long-term outcomes of continuous intrathecal baclofen infusion for treatment of spasticity: a prospective multicenter follow-up study

Long-term outcomes of 115 patients treated with continuous intrathecal baclofen infusion are reported. A prospective follow-up study was conducted in eight centers. Patients were followed up over a 12-month period. The follow-up scores on the three spasticity scales (Ashworth, spasm, and clonus scales) were significantly lower at every follow-up visit in comparison to the intake score, except for the clonus scale scores at 12 months. Improvements in health-related quality of life (EQ-5D) and functionality (SIP-68, functional independence measure) were small and nonsignificant. A significant reduction in severity of self-reported personal problems rating scale was observed. Sixty-six patients had no adverse events. Types of adverse events reported were wound complications (22%), catheter problems (36%), cerebrospinal fluid leakage (25%), and other complications (17%). Intrathecal baclofen reduces spasticity and severity of patient-reported problems but its effect on quality of life and functionality is less apparent. Improvements are desired in selection criteria, design of spinal catheters, and outcome scales.

Complications of intrathecal baclofen pumps in children: experience from a tertiary care center

BACKGROUND/AIMS

Intrathecal baclofen (ITB) therapy is useful in treating spasticity and dystonia but it has many complications, more so in children. The main aim of the study was to look at the complications of ITB pumps in children with the goal of future prevention.

METHODS

Charts of all patients ≤21 years with an ITB pump, implanted by a single pediatric neurosurgeon, at a single center, between 1996 and 2011 were reviewed retrospectively. Data regarding an ITB test trial were also recorded.

RESULTS

During 1996-2011, 119 children (mean age 13.2 years) underwent ITB pump placement; 84% had spastic quadriplegic cerebral palsy. The gross motor function classification system level was ≥4 for most. The pump was removed in 5 (4.2%) patients due to inefficacy. The mean follow-up was 38 months. Mechanical complications requiring pump and/or catheter revision occurred in 19.3% and infections in an additional 21.8%. Seven patients (6%) had meningitis. No complication was noted after 72 months of initial pump insertion, even after pump reinsertion.

CONCLUSION

There is a need for better infection control as well as better pump, catheter and surgical technology to lower the complications of ITB pumps in children.

The diagnosis and management of adults with spasticity

This chapter aims to address the questions of the definition and effective management of spasticity, in order to assist the reader to recognize, assess, and treat people with this impairment. Spasticity is a physiological consequence of an insult to the brain or spinal cord, which can lead to life-threatening, disabling, and costly consequences. It is a common but not inevitable outcome of the upper motor neuron (UMN) syndrome and is characterized by muscle overactivity and high tone spasms, which, if left untreated, will lead to muscle and soft tissue contracture and limb deformity. There have been several attempts to define spasticity. The difficulty reflects the complex features of the syndrome. The most cited definition is by Lance, but does not fulfil all the clinical scenarios seen in clinical practice. The term "spasticity" in the therapeutic world covers the several other features of the UMN syndrome and, therefore, an all embracing definition is probably required as well. Rates for the prevalence of spasticity in different clinical conditions are variable. This may be due to the presence of many patients with mild spasticity, for whom little or no treatment is required for their condition. However, it is estimated that 38% of patients following stroke develop a degree of spasticity and about 19% require pharmacological treatment. Of these about one-third (5% of the total) will benefit from botulinum toxin injections for focal problems. This chapter will inform the reader about the pathophysiology of spasticity, but also includes the practicalities and principles of management, the delivery of its longer term treatments, and the utilization and measurement of relevant outcomes.

Spasticity following spinal cord injury

BACKGROUND

Up to 70% of patients with spinal cord injuries develop spasticity. The main aim of the paper is to provide an overview of spasticity management, primarily in patients with spinal cord injuries.

METHOD

The article is based on literature searches in PubMed using the keyphrases «spasticity» and «spasticity AND spinal cord injury», and own clinical experience and research.

RESULTS

Spasticity may be general, regional or localised. Factors such as an over-filled bladder, obstipation, acute infections, syringomyelia or bone fractures may substantially influence the degree of spasticity and must be determined. An assessment of the clinical and functional consequences for the patient is decisive before management. Active exercise, physiotherapy and peroral drugs are the simplest and cheapest options. Baclofen is the only centrally acting spasmolytic registered in Norway and is the first choice for peroral treatment. Benzodiazepines can also be used. The effect of the tablets is generally limited and there are often pronounced side effects. Local spasticity can be treated with botulinum toxin injections. The effect is time-limited and the treatment must be repeated. International guidelines recommend a combination of botulinum toxin injections and physiotherapy. In cases of regional spasticity, particularly in the lower limbs, intrathecal baclofen administered via a programmable pump may provide a continuous spasm-reducing effect. Orthopaedic surgery or neurosurgery may be an option for selected patients with intractable spasticity.

INTERPRETATION

Spasticity following a spinal cord injury must be assessed regularly. The treatment strategy depends on the degree of functional failure caused by the spasticity and its location.

Intrathecal baclofen therapy--how we do it

Intrathecal baclofen has become an invaluable tool to treat spasticity of various etiologies. Children who benefit from intrathecal baclofen are often significantly underweight due to underlying disease pathology, and they lack adequate soft-tissue mass to effectively provide cover to the pump. Thus, in this population, subfascial implantation is favored over the subcutaneous technique in view of the high frequency of wound dehiscence and subsequent explantation of the pump associated with the latter method. The authors describe and review their unit's adapted subfascial implantation technique that has been performed over a period of 10 years in 182 children. This technique provides better tissue coverage for the pump and has resulted in lowering the risk of complications as compared with the subcutaneous technique.

[Early rehabilitation for neurologic patients]

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients' impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.

Intrathecal baclofen for progressive neurological disease in childhood: a systematic review of literature

BACKGROUND

Intrathecal baclofen (ITB) treatment is frequently used for individuals with severe, but non-progressive, spasticity refractory to oral treatment. However, experiences with ITB in patients with progressive neurological disorders of childhood causing spasticity are limited.

AIM

To investigate whether ITB is an option in patients with progressive neurological disorders causing spasticity in childhood.

DESIGN

A systematic literature search in Embase, Pubmed and the Cochrane Library was performed.

RESULTS

We identified six eligible studies considering patients with progressive neurological disease in childhood and receiving ITB treatment. The studies included a total of seven paediatric patients and four adult patients. Improvement was reported in spasticity, spasms, pain, gait, activities of daily life and providing care. High satisfaction is described.

CONCLUSIONS

ITB has beneficial effects in paediatric patients with progressive neurological disease. However, the level of evidence is limited due to the small number of available studies and due to the poor quality of these studies.

Effects of intrathecal baclofen therapy on motor and cognitive functions in a rat model of cerebral palsy

OBJECT

Cerebral palsy (CP) arises in the early stages of brain development and manifests as spastic paresis that is often associated with cognitive dysfunction. Available CP treatments are aimed at the management of spasticity and include botulinum toxin administration, selective dorsal rhizotomy, and intrathecal baclofen (ITB). In this study, the authors investigated whether the management of spasticity with ITB therapy affected motor function and whether the release of spasticity was associated with an improvement in intellectual function.

METHODS

Newborn Sprague-Dawley rats were divided into the following groups: control, CP model, and CP model with ITB therapy. For the CP model, postnatal Day 7 (P7) rats were exposed to hypoxic conditions (8% O(2)) for 150 minutes after ligation of the right common carotid artery. In the groups receiving ITB therapy, a spinal catheter was connected to an osmotic pump filled with baclofen and placed in the spinal subarachnoid space on P21 in the early group and on P35 in the late group. A daily dose of 12 μg of baclofen was continuously administered until P49, resulting in 28 days of therapy in the early group and 14 days in the late group. Changes in spasticity in the CP and CP with ITB treatment groups were confirmed by assessing the motor evoked potential in the plantar muscle.

RESULTS

In the CP group, the time required to complete a beam-walking test on P49 was significantly longer than that in the control and ITB treatment groups (4.15 ± 0.60 vs 2.10 ± 0.18 and 2.22 ± 0.22 seconds, respectively). Results of the beam-walking test are expressed as the mean ± SD. Radial arm maze performance on P49 indicated that spatial reference memory had significantly deteriorated in the CP group compared with controls (2.33 ± 0.87 vs 0.86 ± 0.90 points); moreover, working memory was also negatively affected by CP (0.78 ± 1.09 vs 0.14 ± 0.38 points). Results of the memory tests are expressed as the mean ± SE. These memory functions did not recover after ITB treatment.

CONCLUSIONS

Management of spasticity with ITB therapy improved the walking ability in the rat CP model. Intrathecal baclofen therapy-which reduces harmful sensory and motor stimulations caused by spasticity to more optimal levels-contributed to motor function recovery; however, it had no effect on intellectual recovery as assessed by memory performance in the rat CP model.

Effects of intrathecal baclofen on daily care in children with secondary generalized dystonia: a pilot study

AIM

Treatment options for dystonic cerebral palsy (CP) are limited. Our aims were to determine whether intrathecal baclofen (ITB) improves daily care, decreases dystonia and decreases pain in patients with dystonic CP.

METHODS

Patients received randomized blinded treatment with ITB or placebo. Scores on problems of daily care were recorded and dystonia, pain and comfort were assessed.

RESULTS

Four patients (three males, average age 12 years 6 months) were included (all Gross Motor Function Classification System level V). During the trial period problem scores and dystonia scores decreased in all four patients.

CONCLUSION

In this pilot study we report positive functional effects of ITB trial treatment in four patients with dystonic CP. A randomized trial with a larger cohort is needed to verify these results.

Use of intrathecal baclofen therapy in ambulant children and adolescents with spasticity and dystonia of cerebral origin: a systematic review

AIM

Studies on the use of intrathecal baclofen (ITB) for ambulant adults with spasticity and/or dystonia of cerebral origin are scarce, and are even more limited for children and adolescents. This systematic review investigates the use of ITB to improve walking, transfer ability, and gross motor activities in ambulant children and adolescents with spasticity and/or dystonia of cerebral origin.

METHOD

Electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, full Cochrane Library, and PEDro) were searched from the earliest date available until March 2011 using combined subject headings and free text if supported by the databases. Studies were included if they had examined individuals who: (1) received ITB therapy by any method (bolus injection, an external delivery system, or an implanted pump); (2) had spasticity and/or dystonia of cerebral origin; (3) were able to ambulate with or without a walking device, i.e. individuals with cerebral palsy (CP) who were in levels I to III of the Gross Motor Function Classification System or individuals with similar functional mobility if they did not have CP; and (4) were aged 18 years or under. Publications in English in peer-reviewed journals reporting any type of research design, except reviews and expert opinions, were included. Studies were excluded if participants had spasticity and/or dystonia of spinal origin and if baclofen was administered only orally. Studies that compared ITB with other interventions such as botulinum toxin were also excluded.

RESULTS

Two independent reviewers scored 16 studies against the guidelines for developing systematic reviews from the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM).

INTERPRETATION

Fifteen studies were of levels IV or V evidence and only one of level II according to the evidence levels of the AACPDM guidelines, but all were of low quality. No study was found on the use of ITB in ambulant children or adolescents with dystonia of cerebral origin. Not all studies used objective outcome measures to assess the ambulation, transfer ability, and gross motor activities of the participants. A proportion of participants showed improvement in all these areas but adverse events were common. A proportion of participants compromised their ambulatory and transfer abilities after ITB. There was no evidence to support the clinical use of ITB in ambulant individuals with hypertonicity without further rigorous longitudinal studies.

Imaging evaluation of intrathecal baclofen pump-catheter systems

ITB pumps are widely used in the treatment of intractable spasticity for many clinical indications, including cerebral palsy and spinal cord injury. High-dose intrathecal administration places the patient at significant risk for withdrawal in the event of device malfunction, necessitating rapid and complete evaluation of the pump-catheter system. This article reviews the approach to imaging evaluation of ITB pump-catheter systems, with specific emphasis on radiography, fluoroscopy, CT, and nuclear scintigraphy.

Intrathecal baclofen therapy for spasticity of cerebral origin--does the position of the intrathecal catheter matter?

OBJECTIVE

To assess the correlation between the position of the intrathecal baclofen therapy catheter with the clinical outcome and response to the spasticity.

METHODS AND RESULTS

A prospective cohort study was done by reviewing the paediatric group of patients with spasticity of cerebral origin who had insertion of a programmable baclofen pump for intrathecal administration in the last 10 years (August 1998 to September 2007). A total of 190 procedures were carried out in 166 patients, under a single paediatric neurosurgeon, with an age range of 18 months-16 years (mean 8.75 years) with follow up of 1-10 years (mean 5 years). The routine post-operative X-rays, which were done as per protocol, were reviewed, and the position of the intrathecal catheter tip was documented in relation to the vertebral bodies. The maintenance intrathecal baclofen dose was 25 microgms to 1,000 microgms (mean 255.8 microgms) based on the clinical response to spasticity. Statistical analysis was carried out to assess the correlation of the position of the tip of the intrathecal catheter with the outcome in spasticity based on GMFCS (Gross Motor Function Classification System) and Ashworth score.

CONCLUSION

In our series, there was no statistically significant correlation between the position of the intrathecal catheter and the clinical response to the spasticity.

Survival of individuals with cerebral palsy receiving continuous intrathecal baclofen treatment: a matched-cohort study

AIM

To determine whether intrathecal baclofen (ITB) changes mortality risk in persons with cerebral palsy (CP).

METHOD

Records were reviewed for all persons with CP who were managed with ITB for hypertonicity at a specialty hospital in Minnesota between May 1993 and August 2007. A comparison cohort was randomly selected from clients of the California Department of Developmental Services who were initially evaluated between 1987 and 1990 and were matched to those with ITB for age, sex, Gross Motor Function Classification System (GMFCS) level, presence or absence of epilepsy, and feeding-tube use. Survival probabilities were estimated using the Kaplan-Meier method, and differences were tested via log-rank.

RESULTS

Three hundred and fifty-nine persons with CP (202 males, 157 females) receiving ITB for hypertonicity (mean age 12y 8mo, SD 7y 9mo, range 3y 1mo to 39y 9mo) were matched to 349 persons without ITB pumps (195 males, 154 females; mean age 12y 7mo, SD 8y 4mo, range 2y 7mo to 40y). The proportion of patients at different GMFCS levels in the ITB and in the non-ITB cohorts, respectively, was as follows: level II 3% and 3%, level III 16% and 16%, level IV 38% and 37%, and level V 43% and 44%. Survival at 8 years of follow-up was 92% (SD 1.9%) in the ITB cohort and 82% (SD 2.4%) in the non-ITB cohort (p<0.001). After adjustment to account for recent trends in improved survival in CP, 8-year survival in the non-ITB cohort was 88%, which was not significantly different from the ITB cohort (p=0.073).

INTERPRETATION

ITB therapy does not increase mortality in individuals with CP and may suggest an increase in life expectancy.

Review: Procedure- and Device-Related Complications of Intrathecal Baclofen Administration for Management of Adult Muscle Hypertonia: A Review

Background. Intrathecal baclofen (ITB) effectively reduces muscle hypertonia; however, associated complications influence its utility and acceptance. Objective. To systematically review the literature on procedure- and device-related complications associated with ITB infusion therapy for adult muscle hypertonia of spinal or cerebral origin. Methods. The authors searched the PubMed database for full-length articles published in English that reported ITB-associated complications in adults. Of 147 articles retrieved, 32 full-length manuscripts and 10 case reports were reviewed in detail. Results. Overall, 558 complications were reported after 1362 pump implants (0.41 per implant). Methods for characterizing complications varied greatly between studies, as did complication rates, ranging from 0 to 2.24 per implant. Of the 558 complications, 148 (27%) were related to surgical procedures, 39 (7%) to pump problems, and 369 (66%) to catheter malfunctions. The overall complication rate was higher for studies that followed patients for more than 18 months on average (mean 0.56/implant) versus studies with shorter follow-up (0.23/implant, P < .05). Although correlation between the number of implants and the number of complications was significant ( r = .58), the goodness of linear fit was poor because of clusters with varied complication rates. Conclusions. Catheter problems are relatively common and more frequent than pump or surgical procedure complications after ITB pump implantation. Higher complication rates should be expected in centers that follow patients for a longer period of time. Standardized data collection and complication-reporting procedures along with appropriate training should be implemented in centers offering ITB treatment for management of muscle hypertonia.

Consensus on the appropriate use of intrathecal baclofen (ITB) therapy in paediatric spasticity

Among features of motor disorders in children, spasticity is associated with considerable morbidity and problems in care, particularly in severely affected patients. Intrathecal baclofen (ITB) has been increasingly used as a relatively specific treatment modality for spasticity. To date, most of the evidence for its use in paediatric patients has come from retrospective and uncontrolled studies, although randomised, controlled trials of screening ITB and ITB therapy itself have recently been published. This consensus statement on the use of ITB in paediatric patients with spasticity was developed on the basis of currently available evidence, with the aim of providing information for clinicians, promoting an expert opinion and a consistent approach to the management of these patients and emphasising the need for further prospective, large-scale studies.

Postdural puncture headache in complex regional pain syndrome: a retrospective observational study

OBJECTIVE

To describe the unusual course of postdural puncture headache (PDPH) after pump implantation for intrathecal baclofen (ITB) administration in patients with complex regional pain syndrome (CRPS)-related dystonia.

DESIGN

Case series based on data collected from 1996 to 2005. Setting. Movement disorders clinic, university hospital.

PATIENTS

A total of 54 patients with CRPS-related dystonia who were treated with ITB.

RESULTS

A high incidence (76%) and prolonged course (median 18 days, range 2 days to 36 months) of PDPH was found. Radionuclide studies performed in two patients with long-lasting symptoms (12-16 months) did not reveal cerebrospinal fluid (CSF) leakage. In patients without signs of CSF leakage (N = 38), epidural blood patches administered in 24 patients were effective in 54%, while ketamine infusions administered in six patients were effective in 67%.

CONCLUSIONS

Our observations may suggest that other mechanisms besides intracranial hypotension play a role in the initiation and maintenance of PDPH in CRPS and stimulate new directions of research on this topic.

Intrathecal baclofen use in adults with cerebral palsy

Intrathecal baclofen (ITB) is an effective treatment for both spasticity and dystonia in people with cerebral palsy (CP). Its use is becoming increasingly common. ITB is typically associated with fewer side effects than the oral form of the product, but there are risks related to the hardware needed for intrathecal delivery. Much of what has been reported in the literature about ITB is based on experience with children or groups of children and adults; few reports exclusively address its use in adults with CP. These reports indicate that muscle tone is consistently reduced, but there is some variability in functional outcomes. Few well-controlled studies have been done. Controversies remain concerning ITB, including whether a trial is needed before pump implantation, proper catheter tip placement, and programming options, as well as whether it contributes to the development or progression of scoliosis. These and other unanswered questions should be addressed in a systematic way.

[Transition from childhood to adulthood and management of spasticity]

The authors report specific concerns on the transition to adulthood in cerebral palsy patients, with particular attention devoted to spasticity treatment follow-up.