Intrathecal Baclofen Management of Poststroke Spastic Hypertonia: Implications for Function and Quality of Life

Challenges of Hip Arthroplasty in a Paretic, Spastic Limb: A Case Study on Managing Femoral Neck Fracture Following Fixation Failure in a Hemiparetic Patient

Background: Hip fractures and strokes are prevalent and escalating issues in geriatric healthcare. The absence of standardized surgical protocols for patients with spastic hemiparesis and multiple comorbidities presents a significant medical challenge. Methods: This case study describes a 64-year-old male patient with left-sided hemiparesis and failed surgical treatment of a pertrochanteric fracture in a spastic limb. The patient was admitted to the Department of Rehabilitation and Orthopedics in December 2022 for diagnostics and to establish a treatment plan after five months of non-ambulatory status. Results: This study emphasizes the crucial role of preoperative preparation, involving botulinum toxin injections into spastic muscles and physiotherapy, to enhance the supportive function of the paretic limb and improve locomotion before prosthetic surgery. Conclusions: The management of hip fractures in patients with spastic paralysis requires a multidisciplinary approach and the development of standardized treatment protocols. This case underscores the importance of comprehensive pre- and postoperative rehabilitation to improve patient outcomes. Further research is needed to establish standardized rehabilitation protocols for spastic patients undergoing hip arthroplasty. Randomized controlled trials could provide valuable insights into the efficacy of various interventions.

Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales: A Retrospective Analysis

Introduction

Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic.

Materials and Method

Sixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods.

Results

The sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00).

Conclusion

Intrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.

Sustained Baclofen-Induced Activation of GABA B Receptors After Cerebral Ischemia Restores Receptor Expression and Function and Limits Progressing Loss of Neurons

One important function of GABA_B receptors is the control of neuronal activity to prevent overexcitation and thereby excitotoxic death, which is a hallmark of cerebral ischemia. Consequently, sustained activation of GABA_B receptors with the selective agonist baclofen provides neuroprotection in in vitro and in vivo models of cerebral ischemia. However, excitotoxic conditions severely downregulate the receptors, which would compromise the neuroprotective effectiveness of baclofen. On the other hand, recent work suggests that sustained activation of GABA_B receptors stabilizes receptor expression. Therefore, we addressed the question whether sustained activation of GABA_B receptors reduces downregulation of the receptor under excitotoxic conditions and thereby preserves GABA_B receptor-mediated inhibition. In cultured neurons subjected to oxygen and glucose deprivation (OGD), to mimic cerebral ischemia, GABA_B receptors were severely downregulated. Treatment of the cultures with baclofen after OGD restored GABA_B receptor expression and reduced loss of neurons. Restoration of GABA_B receptors was due to enhanced fast recycling of the receptors, which reduced OGD-induced sorting of the receptors to lysosomal degradation. Utilizing the middle cerebral artery occlusion (MCAO) mouse model of cerebral ischemia, we verified the severe downregulation of GABA_B receptors in the affected cortex and a partial restoration of the receptors after systemic injection of baclofen. Restored receptor expression recovered GABA_B receptor-mediated currents, normalized the enhanced neuronal excitability observed after MCAO and limited progressive loss of neurons. These results suggest that baclofen-induced restoration of GABA_B receptors provides the basis for the neuroprotective activity of baclofen after an ischemic insult. Since GABA_B receptors regulate multiple beneficial pathways, they are promising targets for a neuroprotective strategy in acute cerebral ischemia.

Intrathecal Baclofen for Severe Spasticity: Longitudinal Data From the Product Surveillance Registry

Objective

To assist in the assessment of intrathecal baclofen (ITB) therapy risks and benefits by providing surgical intervention rate, safety, and elective device replacement rate data.

Materials and Methods

An ongoing prospective, long‐term, multicenter Product Surveillance Registry (PSR) (NCT01524276) enrolled consented patients implanted with the SynchroMed II infusion system. Pump and catheter performance data were collected, with patients followed prospectively for events related to the device, procedure, and therapy. Investigators provided event descriptions, patient symptoms, and patient outcomes.

Results

We analyzed registry data from 1743 patients (77% adult, 46.8% female) treated with ITB for severe spasticity at 53 registry sites between August 2003 and October 2017, for an accumulated 6481 patient‐years. Discontinuation from the registry was largely (58.6% of discontinued patients) due to study site closure and patient relocation; exit due to an adverse event was limited to 0.3%. After 10 years, 87.2% of adult and 76.3% of pediatric patients continued with ITB. Overall, 99.1% of pumps reaching end of battery life were replaced at the time of explant.

Conclusions

ITB therapy for the treatment of severe spasticity requires surgical implantation of a programmable infusion system for chronic drug delivery. If complications arise, many necessitate surgical intervention for correction. For spinal and cerebral spasticity in pediatric and adult patients, discontinuation rates due to an adverse event were low (0.3%), and there was high acceptance (99.1%) of surgical intervention for therapy continuation. Patient/caregiver willingness to accept surgical and other risks for therapy continuation was extremely high.

Intrathecal Baclofen Therapy in Russia: National Register, the Effect of One-Year Usage

Patients with severe muscular spasticity still represent the most complex and resistant to therapy group of neuro-rehabilitation patients. In a few years, in Russia, intrathecal baclofen therapy has appeared to be the most effective method for such spasticity. For the first time the authors developed and implemented in clinical practice “Prospective register to treat spastic states using intrathecal baclofen therapy in Russian Federation” aimed at therapy classification of spastic patients: to reveal management characteristics, assess treatment outcomes and frequency of occurrence of adverse events that will finally help specify the need for the method employment in real clinical practice.

The article presents the findings of a one-year usage of Register, which enabled to make a preliminary evaluation of intrathecal baclofen therapy in Russia.

Effect of Intrathecal Baclofen on Pain and Quality of Life in Poststroke Spasticity

Background and Purpose- Intrathecal baclofen (ITB) is an effective treatment for managing patients with severe poststroke spasticity, who can experience continued pain and decline in their quality of life (QoL). SISTERS (Spasticity In Stroke-Randomized Study) was a randomized, controlled, open-label, multicenter, phase 4 study to evaluate ITB therapy versus conventional medical management (CMM) with oral antispastic medications for treatment of poststroke spasticity. Methods- Poststroke patients with spasticity in ≥2 extremities and an Ashworth Scale score of ≥3 in ≥2 affected lower extremity muscle groups were randomized (1:1) to ITB (N=31) or CMM (N=29). Both treatment arms received physiotherapy throughout. The primary outcome was the change in average Ashworth Scale score in the lower extremities of the affected side from baseline to month 6. Here, we report results for secondary outcomes: pain via the Numeric Pain Rating Scale, health-related QoL by the EuroQol-5 dimensional 3 level utility score and health status visual analog scale score, stroke-specific QoL, and patient satisfaction. Analyses were performed on an intention-to-treat basis. Results- We observed significant treatment effects in favor of ITB over CMM for changes from baseline to month 6 in Numeric Pain Rating Scale scores for actual pain (ITB versus CMM: mean, -1.17 [SD, 3.17] versus 0.00 [3.29]; median, -1.00 versus 0.00; P=0.0380) and least pain (mean, -1.61 [2.29] versus 0.24 [3.07]; median, -1.00 versus 0.00; P=0.0136), and EuroQol-5 dimensional 3 level utility scores (mean, +0.09 [0.26] versus +0.01 [0.16]; median, +0.07 versus 0.00; P=0.0197). Between-group differences were not statistically significant for EuroQol-5 dimensional 3 level visual analog scale, stroke-specific QoL summary, or Numeric Pain Rating Scale worst pain scores, although ITB patients showed greater numeric improvements from baseline during follow-up. More ITB patients than CMM patients (73% versus 48%) were satisfied with the spasticity reduction at month 6. Conclusions- These data support that ITB therapy is associated with improvements in pain and QoL in poststroke patients. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01032239.

Intrathecal Baclofen Trial Before Device Implantation: 12-Year Experience With Continuous Administration

OBJECTIVE

To report our experience using continuous intrathecal baclofen (ITB) administration prior to a possible ITB device implantation.

DESIGN

Retrospective open label study. Mean duration of follow-up 64 months.

SETTING

Primary-care and referral center, ambulatory and hospitalized care.

PARTICIPANTS

Patients (N=116) undergoing continuous ITB trials between 2006 and 2017.

INTERVENTIONS

Continuous application of baclofen via a temporary intrathecal catheter connected to an external pump.

MAIN OUTCOME MEASURES

Assessment of the modified Ashworth Scale and range of movement prior versus end of ITB trial. According to the Barthel Index, definition of high-level patients (60-100 scoring points) and low-level patients (0-55 scoring points). Calculation of the Rivermead Mobility Index in high-level patients prior versus end of ITB trial. Evaluation of occurring adverse events.

RESULTS

A total of 119 ITB trials were performed in 116 patients (78 men, mean age 41±16), 113 patients completed the trials (31 of 113 high level, 82 of 113 low level). The median modified Ashworth scale improved from 4 (interquartile range [IQR] 3-4) to 2 (IQR 1-2; P≤.001), the range of movement from 2 (IQR 1-3) to 3 (IQR 3-3; P≤.001). The Rivermead Mobility Index increased from 9 (IQR 6-12) to 10 (IQR 7-12.5; P=.004) in high-level patients. Eighty-eight out of 113 patients (78%) were appropriate candidates for ITB device surgery, 75 of 88 (85%) proceeded to an implantation. A total of 69 adverse events occurred in 57 of 119 trials (48%), 37 of 69 (54%) were drug related, 32 of 69 (46%) were procedure related, and 42 of 69 (61%) were minor. The ITB device was implanted in 69 of 75 patients (92%) at last follow-up.

CONCLUSIONS

Continuous administration of ITB is an effective and useful alternative to ITB bolus application during ITB screening period. Half of the patients experienced adverse events; the majority were minor events.

Intrathecal baclofen therapy versus conventional medical management for severe poststroke spasticity: results from a multicentre, randomised, controlled, open-label trial (SISTERS)

BACKGROUND

Intrathecal baclofen (ITB) is a treatment option for patients with severe poststroke spasticity (PSS) who have not reached their therapy goal with other interventions.

METHODS

'Spasticity In Stroke-Randomised Study' (SISTERS) was a randomised, controlled, open-label, multicentre phase IV study to evaluate the efficacy and safety of ITB therapy versus conventional medical management (CMM) with oral antispastic medications for treatment of PSS. Patients with chronic stroke with spasticity in ≥2 extremities and an Ashworth Scale (AS) score ≥3 in at least two affected muscle groups in the lower extremities (LE) were randomised (1:1) to ITB or CMM. Both treatment arms received physiotherapy throughout. The primary outcome was the change in the average AS score in the LE of the affected body side from baseline to month 6. Analyses were performed for all patients as randomised (primary analysis) and all randomised patients as treated (safety analysis).

RESULTS

Of 60 patients randomised to ITB (n=31) or CMM (n=29), 48 patients (24 per arm) completed the study. The primary analysis showed a significant effect of ITB therapy over CMM (mean AS score reduction, -0.99 (ITB) vs -0.43 (CMM); Hodges-Lehmann estimate, -0.667(95.1%CI -1.0000 to -0.1667); P=0.0140). More patients reported adverse events while receiving ITB (24/25 patients, 96%; 149 events) compared with CMM (22/35, 63%; 77 events), although events were generally consistent with the known safety profile of ITB therapy.

CONCLUSIONS

These data support the use of ITB therapy as an alternative to CMM for treatment of generalised PSS in adults.

TRIAL REGISTRATION NUMBER

NCT01032239; Results.

Management of intrathecal baclofen therapy for severe acquired brain injury: consensus and recommendations for good clinical practice

Although widespread in the treatment of generalised spasticity due to severe acquired brain injury, clinical use of intrathecal baclofen administered through an implanted catheter is not yet supported by full scientific evidence. The aim of the study is to provide recommendations for good clinical practice regarding intrathecal baclofen therapy. We used a modified RAND Delphi method to develop consensus-based medical guidelines, involving clinicians who use intrathecal baclofen therapy throughout Italy. The clinicians were asked 38 questions grouped in six areas (patient selection, contraindications for implant, tests prior to implant, method of implant and management of therapy, efficacy evaluation and goal setting, and management of complications). To establish consensus, 75% agreement was required in answers to every question. Consensus was reached on the second round of the Delphi process on 27/38 questions (71%), specifically those regarding identification of objectives, efficacy evaluation, and method of implant and management of therapy, whereas management of complications and contraindications for implant remained critical areas. Despite the limits of our method, a set of recommendations was drawn up for clinical practice in this sector. The study also revealed residual critical areas and indicated future lines of research necessary to reach evidence-based consensus.

Demystifying Poststroke Pain: From Etiology to Treatment

Pain after stroke is commonly reported but often incompletely managed, which prevents optimal recovery. This situation occurs in part because of the esoteric nature of poststroke pain and its limited presence in current discussions of stroke management. The major specific afflictions that affect patients with stroke who experience pain include central poststroke pain, complex regional pain syndrome, and pain associated with spasticity and shoulder subluxation. Each disorder carries its own intricacies that require specific approaches to treatment and understanding. This review aims to present and clarify the major pain syndromes that affect patients who have experienced a stroke in order to aid in their diagnosis and treatment.

Best Practices for Intrathecal Baclofen Therapy: Dosing and Long-Term Management

INTRODUCTION

Intrathecal baclofen (ITB) therapy aims to reduce spasticity and provide functional control.

METHOD

An expert panel consulted on best practices.

RESULTS

Pump fill and drug delivery can be started intraoperatively, with monitoring for at least eight hours. Initiate with the 500 mcg/mL concentration. The starting daily dose should be twice the effective bolus screening dose, or the screening dose if the patient had a prolonged response (greater than eight hours) or negative reactions. Oral antispasmodics can be weaned, one drug at a time beginning with oral baclofen after ITB begins. Assessment should occur within 24 hours of a dose change. For adults, daily dose increases may be 5% to 15% once every 24 hours for cerebral-origin spasticity and 10% to 30% once every 24 hours for spinal-origin spasticity. Daily dose increases can be 5% to 15% once every 24 hours for children. Inpatients should be assessed at least every 24 hours and receive rehabilitation. Step dosing can be used for outpatients who cannot return daily. Dosing options include simple continuous dosing, variable 24-hour flex dosing, or regularly scheduled boluses. Patients/caregivers should understand the care plan, responsibilities, and possible side-effects. Low-reservoir alarm dates and refill schedules should be written down, along with emergency contact information. A higher concentration at refill can extend refill intervals, and a bridge bolus must be programmed. Time changes may affect flex dosing. Pump replacement should be scheduled at least three months in advance.

CONCLUSIONS

ITB dosing is multistep and individualized.

Best Practices for Intrathecal Baclofen Therapy: Screening Test

INTRODUCTION

Intrathecal baclofen (ITB) screening assesses response to a test dose of ITB on spasticity and function and identifies adverse reactions.

METHOD

An expert panel consulted on best practices after conducting an extensive literature search and conducting an online survey.

RESULTS

A successful trial may confirm predetermined goals, which may include improved mobility/positioning, decreased time/improved independence for activities, less home exercise, better wheelchair tolerance, decreased caregiver time, improved sleep, and reduced pain, or may modify goals and expectations. Individuals should not be tested in the presence of active medical issues (e.g., MS exacerbations, active urinary tract infection, nonhealing wounds). Oral antispasmodics can be weaned before trial if a goal is to eliminate them. The standard baclofen test dose is a 50-mcg bolus, 25 mcg in very small children or patients who rely on spasticity for mobility. Patients unresponsive to the standard dose may require 75 mcg or 100 mcg; 24 hours should elapse between bolus doses. Cardiopulmonary parameters should be checked frequently during the first two hours postinjection, and spasticity measures assessed at least twice within four hours. Observation continues until the patient is stable and recovers from hypertonia. Adverse events include spinal headaches, nausea/vomiting, urinary retention, hypotension, seizures, drowsiness/sedation, respiratory depression, and coma. Before implantation, team members must discuss starting dose, drug concentration, delivery mode, pump size and location, and catheter tip placement. Patients/caregivers should understand the commitment necessary for ITB therapy.

CONCLUSIONS

Screening helps identify appropriate candidates for ITB.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Three Case Reports of Successful Vibration Therapy of the Plantar Fascia for Spasticity Due to Cerebral Palsy-Like Syndrome, Fetal-Type Minamata Disease

Fetal-type Minamata disease is caused by the exposure to high concentrations of methylmercury in the fetal period and shows cerebral palsy-like clinical features. Relief of spasticity is a major task of rehabilitation to improve their activities of daily living. Here we report the effect of long-term vibration therapy on bilateral lower-limb spasticity in 3 patients with fetal-type Minamata disease. We used a simple, inexpensive, and noninvasive approach with hand-held vibration massagers, which were applied to the plantar fascia at 90 Hz for 15 minutes. The effect was observed soon after the first treatment and resulted in better performance of the repetitive facilitation. Vibration therapy for 1 year improved Modified Ashworth Scale for the ankle flexors in 2 cases. The labored gait improved and gait speed increased in another case. Continued vibration therapy for another 1 year further improved Modified Ashworth Scale score and range of motion of ankle dorsiflexion in 1 case. This case showed the decreased amplitude of soleus H-reflex after the 15-minute vibration therapy, suggesting that α-motor neuron excitability was suppressed. Vibration therapy using a hand-held vibration massager may offer safe and effective treatment for lower-limb spasticity in patients with chronic neurological disorders.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation

OBJECTIVE

To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation.

DESIGN

Retrospective chart review.

SETTING

An inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics.

PARTICIPANTS

Fifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012.

METHODS

Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored.

MAIN OUTCOME MEASURES

Modified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation.

RESULTS

Spasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1).

CONCLUSIONS

Continuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.

Effect of Intrathecal Baclofen Bolus Injection on Ankle Muscle Activation During Gait in Patients With Acquired Brain Injury

Background. Intrathecal baclofen (ITB) bolus injection effectively decreases spinal excitability but the impact on lower limb muscle activation during gait has not been thoroughly investigated. Objective. Examine activation of medial gastrocnemius (MG) and tibialis anterior (TA) muscles during gait before and after ITB bolus injection in patients with resting hypertonia after acquired brain injury. Methods. Lower extremity Ashworth score, temporospatial gait parameters, characteristics of the linear relationship between electromyogram (EMG) and lengthening velocity (LV) in MG during stance, and the duration and magnitude of TA-MG coactivation were assessed before and at 2, 4, and 6 hours after a 50-µg ITB injection via lumbar puncture in 8 hemorrhagic stroke and 11 traumatic brain injury subjects. Results. Temporospatial gait parameters did not significantly differ across the evaluation points ( P ≥ .170). However, Ashworth score ( P < .001), frequency and gain of significant positive EMG-LV slope ( P ≤ .020), and duration of TA-MG coactivation ( P ≤ .013) significantly decreased in the more-affected leg after ITB bolus. EMG changes were not significantly different between patients who did (n = 10) and did not (n = 9) increase gait speed after the injection. The timing of the largest decrease in Ashworth score and the largest decrease in EMG parameters coincided in 36% of cases, on average. Conclusions. ITB bolus injection alters the activation of MG and TA during gait. However, the changes in muscle activation are not closely related to the changes in gait speed or resting muscle hypertonia. The analysis of ankle muscle activation during gait better characterizes the response to ITB bolus injection than gait kinematics.

Neuromodulation using intrathecal baclofen therapy for spasticity and dystonia

Intrathecal baclofen (ITB) therapy is a treatment for intractable spasticity due to a variety of causes. Continuous intrathecal administration of baclofen, an agonist of the inhibitory neurotransmitter γ-aminobutyric acid, inhibits excitation of motor neurons at the spinal level and thus suppresses spasticity. This therapy was introduced clinically in the Europe and the United States in the 1990s, and was finally approved by the Japanese Ministry of Health, Labour and Welfare in Japan in 2005. Clinical use has been permitted since 2006, and reports of therapeutic efficacy are now appearing in Japan. ITB therapy is a non-destructive treatment that enables administration of baclofen from an implantable pump under the control of a programmer, and represents an outstanding treatment method offering both reversibility and adjustability. Indications for ITB therapy have been expanding in recent years to include not only spasticity, but also various causes dystonia. And ITB therapy can greatly improve activities of daily living and quality of life, and this treatment is attracting attention as a neuromodulatory therapy that also affects metabolic and respiratory functions and even state of consciousness. We here report the surgical methods and therapeutic outcomes for 22 patients who underwent ITB therapy for spastic and dystonic patients in our hospital, together with an investigation of the effects on metabolic and respiratory functions.

A meta-analysis evaluating the effectiveness of two different upper limb hemiparesis interventions on improving health-related quality of life following stroke

PURPOSE

The aim of this article is to quantitatively assess the efficacy of different upper limb interventions on health-related quality of life (QOL) in stroke patients.

METHOD

Two botulinum type A injection (BTX-A) studies and 4 constraint-induced movement therapy (CIMT) studies were separately combined in a meta-analysis using a fixed effects model. QOL mean scores were extracted and transformed into weighted mean differences.

RESULTS

Combined, the BTX-A studies showed no significant improvements in overall health-related QOL. Similarly, a meta-analysis of 4 CIMT studies revealed nonsignificant findings for the domains of activities of daily living, communication, and hand function. A separate meta-analysis of 3 CIMT studies showed a significant increase in strength scores (P = .007); however, sensitivity analysis for this domain due to significant heterogeneity led to a newP value of .078, showing a nonsignificant increase in strength. Further results for memory, mobility, mood, participation, and overall recovery were all nonsignificant.

CONCLUSION

This report did not show these types of upper limb interventions to be effective in improving health-related QOL in the poststroke population.

Prospective 12-month study of intrathecal baclofen therapy for poststroke spastic upper and lower extremity motor control and functional improvement

OBJECTIVES

To assess the effects of intrathecal baclofen (ITB) therapy for the treatment of poststroke spastic hemiparesis on quality of life, functional independence, and upper, lower extremity (UE, LE) motor functions.

MATERIALS AND METHODS

Prospective observational study of adult men and women with a minimum 6-month stroke-related spastic hemiparesis graded as ≥2 in UE and LE on Modified Ashworth Scale (MAS). Patients served as their own controls with measures compared pre-implant with 12 months post ITB including: MAS, manual muscle test (MMT), gait distance/velocity, Functional Independence Measures (FIM), stroke-specific quality of life scale (SSQL), and upper extremity manual activity log.

RESULTS

After 12-month ITB therapy, 26 patients (poststroke=6.4±9 years) demonstrated 1) reduced MAS/increased MMT for most LE muscle groups (p≤0.0001); 2) reduced MAS/increased MMT most UE muscle groups (p≤0.01); 3) FIM scores improved (p≤0.05) except bed mobility and lower body dressing; 4) gait distance and velocity improved (p≤0.05); 5) SSQL domains of family roles, mobility, personality, self-care, social roles, thinking, UE function, and work/productivity improved (p≤0.05); 6) amount of use and quality of movement of the spastic UE in performing common activities of daily living increased (p<0.0001).

CONCLUSIONS

Regardless of duration of spastic hemiparesis, a reduction in tone with ITB therapy facilitates motor strength improvement and is associated with clinically significant improvements in functional independence and quality of life.

Consciousness recovery induced by intrathecal baclofen administration after subarachnoid hemorrhage -two case reports-

Two patients with subarachnoid hemorrhage recovered consciousness after intrathecal baclofen administration using an implanted intrathecal baclofen pump delivering 50 microg per day using a simple infusion mode. Intrathecal baclofen resulted in significant reduction of spasticity 3 months after the implantation. Case 1 was reduced to a completely bedridden state with spasticity and could slightly move her fingers following commands. However, the patient could eat food and wash her face with minimal assistance at 3 months after the implantation, and could stand up in the parallel bars with assistance and speak several words at 8 months. Case 2 was in a completely bedridden state at 10 months after onset and could neither drink water nor follow instructions. However, the patient became oriented and could eat by herself within 3 to 4 weeks of implantation. She could walk with a cane and use the stairs with minimal assistance at 2 and 3 months after implantation. The patient could speak fluently within 6 months of implantation. Flatulence and dysuria happened during the screening test, but these symptoms were not repeated after implantation of a pump-catheter-system and continuous intrathecal baclofen infusion. Continuous intrathecal baclofen infusion caused both improvement in muscle tone and spasms and consciousness recovery from the vegetative state. This therapy is a strong candidate treatment for patients with spasticity and consciousness disturbance.

Combined Bracing, Electrical Stimulation, and Functional Practice for Chronic, Upper-Extremity Spasticity

OBJECTIVE. Conventional methods for managing upper-extremity (UE) spasticity are invasive, usually require readministration after a certain time period, and do not necessarily increase UE function. This study examined efficacy of combining two singularly efficacious modalities—UE bracing and electrical stimulation—with functional training to reduce UE spasticity and improve function.

METHOD. Two chronic stroke patients exhibiting UE spasticity were administered the Modified Ashworth Scale (MAS), the upper-extremity section of the Fugl-Meyer Impairment Scale (FM), the Box and Block Test (B&B), and the Arm Motor Ability Test (AMAT). They were then individually fitted for a brace and subsequently participated in treatment sessions occurring 2 days/wk for 5 wk, consisting of (1) 30-min clinical sessions, during which the UE was braced in a functional position while cyclic electrical stimulation was applied to the antagonist extensors of the tricep and forearm, and (2) 15-min, clinically based training sessions, occurring directly after the clinical session.

RESULTS. After intervention, participants exhibited 1-point reductions in MAS scores for the affected fingers, FM score increases, and increased ability to perform AMAT activities,. Three months later, both participants retained these changes.

CONCLUSION. Data point to a noninvasive, promising method of managing spasticity and rendering functional changes.

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.

Intrathecal baclofen for spasticity management: a comparative analysis of spasticity of spinal vs cortical origin

BACKGROUND/OBJECTIVE

To examine the differences in intrathecal baclofen management of individuals with spasticity of cortical vs spinal etiologies.

DESIGN

Retrospective chart review of 57 individuals with the diagnoses of severe cortical and spinal spasticity requiring an intrathecal baclofen pump.

METHODS

Parameters evaluated included daily dosage of medication required, flex vs simple continuous delivery modes, dosing changes, need for other local spasticity treatment, and catheter complications.

RESULTS

There were no statistically significant differences between individuals with cortical spasticity and spinal spasticity when comparing daily dosage, number of contacts, and mode of delivery. At 6 months, there was a statistically significant difference in dosing between individuals with multiple sclerosis and those without. Within groups, there was a significant difference in average daily dosing over 3 years. A significant difference was found comparing the use of botulinum toxin type A for upper extremity spasticity within the cortical group. Nine individuals had catheter complications.

CONCLUSIONS

Cortical and spinal spasticity appear to parallel each other with no significant differences in daily dosing, dosing changes, and mode of delivery of intrathecal baclofen. This did not hold true at all time points for the multiple sclerosis subgroup. The significant difference noted within groups for daily dosing over the first 3 years challenges the notion of stable dosing over time. Focal injections of Botox/phenol in the upper extremities are an important adjunct therapy for patients with cortical spasticity, even after the placement of an intrathecal baclofen pump. Our complication rate was slightly lower than that reported in the literature.

Potential clinical impact of compounded versus noncompounded intrathecal baclofen

OBJECTIVE

To assess the differences between commercial and pharmacy-compounded preparations of baclofen for intrathecal administration.

DESIGN

Random sample.

SETTING

Pharmacies in the United States advertising compounded intrathecal baclofen preparation.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Intrathecal baclofen (ITB) samples were collected from 1 Food and Drug Administration-approved commercial source and 6 compounding pharmacies. An independent analysis of drug concentration and density was conducted. Information regarding ordering process, manufacturing, packaging, storage, and expiration was collected.

MAIN OUTCOME MEASURE

Comparison of concentration and density variations.

RESULTS

Twenty-nine ITB samples in concentrations of 2000, 3000, 4000, 5000, and 6000 microg/mL were analyzed. Over 40% of compounded samples were more than 5% above or below labeled concentration. Twenty-two percent of compounded samples were more than 10% above or below labeled concentration. The only samples with no concentration deviation and consistent drug density were the commercially available, noncompounded products.

CONCLUSIONS

Compounding pharmacies have variable practices in the provision of ITB. A high incidence of concentration inaccuracy existed. The use of compounded ITB may result in unintended dose alterations. Variable clinical efficacy, or life-threatening overdose or withdrawal may occur in patients who are sensitive to slight dose fluctuations. Given the variability of these compounded ITB samples, informed consent to use these products and understanding of potential side effects should be reviewed with patients.

Stroke rehabilitation: strategies to enhance motor recovery

Recent evidence indicates that the brain can remodel after stroke, primarily through synaptogenesis. Task-specific and repetitive exercise appear to be key factors in promoting synaptogenesis and are central elements in rehabilitation of motor weakness following stroke. Expert medical management ensures a patient is well enough to participate in rehabilitation with minimal distractions due to pain or depression. Contraint-induced motor therapy and body-weight-supported ambulation are forms of exercise that "force use" of an impaired upper extremity. Technologies now in common use include robotics, functional electrical stimulation, and, to a lesser degree, transcranial magnetic stimulation and virtual reality. The data on pharmacological interventions are mixed but encouraging; it is hoped such treatments will directly stimulate brain tissue to recovery. Mitigation of factors preventing movement, such as spasticity, might also play a role. Research evaluating these motor recovery strategies finds them generally good at the movement level but somewhat less robust when looking at functional performance. It remains unclear whether inconsistent evidence for functional improvement is a matter of poor treatment efficacy or insensitive outcome measures.

Limitations of Intrathecal Baclofen for Spastic Hemiparesis Following Stroke

Objective. Intrathecal baclofen (ITB) has become the first choice in the management of deleterious spasticity that does not respond to oral and intramuscular medications following spinal cord injury, traumatic brain injury, and cerebral palsy. The usefulness of ITB in severe spastic hemiparesis following stroke is studied. Methods. A total of 8 patients underwent clinical and video assessment following ITB bolus application (n = 5) and during continuous infusion via a temporary catheter system (n = 3). Results. The mean daily dosage alleviating spasticity on the hemiparetic side—without affecting the nonparetic side—was 119 μg/day (range 50 to 360 μg/day). However, 6 patients experienced functional deterioration as ITB weakened their paretic side such that the antigravity pattern they used for ambulation was suppressed. In 2 patients, spasticity-associated pain and spasms subsided and they underwent implantation of a long-term drug delivery system. Conclusions. ITB may reduce spasticity in a dose-dependent manner irrespective of its origin. Although not primarily antinociceptive in humans, ITB may alleviate pain if arising from increased muscle tone. A functional benefit may result if ITB can uncover “subclinical” motor control that had been suppressed by spasticity. However, when a patient uses antigravity patterns for ambulation in the absence of more complex motor control, ITB may cause the loss of residual walking ability, which becomes a major limitation for patients with hemiplegic stroke.

Intrathecal pumps

Direct neuroaxis drug delivery has expanded the physician's armamentarium to provide treatment options to those who have failed more conservative interventions. Starting from Bier's 'cocainization of the spinal cord' in 1898, direct nervous system pharmacy delivery has long been recognized as an effective means to treat pain. Intrathecal pump systems are now commonplace in the management of numerous pain states, as well as of neuromuscular sequelae of central nervous system injury. There has been much advancement in the physiologic and pharmacologic understanding of direct neuromodulation, providing a growing number of treatment options depending on the specific disease state. As well, surgical techniques and catheter systems have undergone refinements providing improved long-term safety and efficacy. We present a review of the historical evolution to current intrathecal therapies, as well as a dialog regarding patient selection, drug options, and side effects. Also, included is a discussion of surgical techniques, current delivery options and complications concerning pump placement.