Intrathecal baclofen in subjects with spastic hemiplegia: assessment of the antispastic effect during gait

Effects of ankle-foot orthosis with dorsiflexion resistance on the quasi-joint stiffness of the ankle joint and spatial asymmetry during gait in patients with hemiparesis

BACKGROUND

Reduced ankle quasi-joint stiffness affects propulsion in the paretic side of patients with hemiparesis, contributing to gait asymmetry. We investigated whether the use of an ankle-foot orthosis with dorsiflexion resistance to compensate for reduced stiffness would increase quasi-joint stiffness and spatiotemporal symmetry in patients with hemiparesis.

METHODS

Seventeen patients walked along a 7-m walkway in both ankle-foot orthosis with dorsiflexion resistance and control (i.e., ankle-foot orthosis) conditions. Dorsiflexion resistance by spring and cam was set to increase linearly from zero-degree ankle dorsiflexion. Gait data were analyzed using a three-dimensional motion analysis system.

FINDINGS

Ankle-foot orthosis with dorsiflexion resistance significantly increased the quasi-joint stiffness in the early and middle stance phase (P = 0.028 and 0.040). Furthermore, although ankle power generation in the ankle-foot orthosis with dorsiflexion resistance condition was significantly lower than in the control condition (P = 0.003), step length symmetry significantly increased in the ankle-foot orthosis with dorsiflexion resistance condition (P = 0.016). There was no significant difference in swing time ratio between conditions.

INTERPRETATION

Applying dorsiflexion resistance in the paretic stance phase increased quasi-joint stiffness but did not lead to an increase in ankle power generation. On the other hand, applying dorsiflexion resistance also resulted in a more symmetrical step length, even though the ankle joint power generation on the paretic side did not increase as expected. Future research should explore whether modifying the magnitude and timing of dorsiflexion resistance, considering the biomechanical characteristics of each patients' ankle joint during gait, enhances ankle joint power generation.

The impact of intrathecal baclofen on the ability to walk: A systematic review

OBJECTIVE

Intrathecal baclofen (ITB) is an effective treatment for lower limb spasticity. In ambulatory patients with spasticity, there is a justifiable concern that ITB treatment may compromise ambulatory function by reducing the heightened muscle tone, thereby unmasking underlying muscle weakness. ITB is hence offered with reservation in ambulant patients. In this article, we review the literature surrounding the effect of ITB therapy on ambulatory function in patients with concurrent spasticity and discuss the key findings.

DATA SOURCES

A literature search of ProQuest Medline and EBSCO CINAHL databases was performed.

REVIEW METHOD

Inclusion criteria included (a) studies reporting the effect of ITB in adult ambulatory patients; (b) studies with an intervention of screening test trial via either bolus injections or continuous infusion tests; and (c) studies with an intervention of ITB pump implantation. Seventeen eligible studies were identified and two authors independently assessed the study quality using the risk of bias in nonrandomised studies of interventions tool (ROBINS-I).

RESULTS

Seventeen studies were included, with a total of 534 participants. Most of the patients remain ambulatory after ITB treatment, accompanied by improvements in gait speed and reduction in spasticity.

CONCLUSION

ITB therapy when administered in carefully selected ambulatory patients with spasticity is not associated with loss of ambulatory function.

Knee Muscle Stretch Reflex Responses After an Intrathecal Baclofen Bolus in Neurological Patients With Moderate-to-Severe Hypertonia

OBJECTIVES

To examine the prevalence, onset threshold, and response magnitude of stretch reflex response (SRR) in the knee extensors and flexors before and after an intrathecal baclofen (ITB) bolus injection in patients with moderate-to-severe hypertonia.

MATERIALS AND METHODS

SRRs were elicited by reciprocal passive knee extension/flexion movements at preset angular velocities of 5, 60, 120, 180, 240, and 300°/s using an isokinetic dynamometer and recorded with surface electromyographic (EMG) electrodes placed over the knee extensors and flexors in 53 neurologic patients before and at 2.5 and 5 hours after an ITB injection via lumbar puncture. Outcome measures included the number of patients with presence/absence of SRRs, the number of SRRs per session, SRR onset threshold angle and velocity, and response magnitudes (peak EMG and area under the EMG curve) for each muscle. Pre-post comparisons were completed using the Fisher's exact and Wilcoxon signed rank tests.

RESULTS

For both knee extensors and flexors, the proportion of patients with present SRRs (p < 0.0001) and the number of SRRs per session (p ≤ 0.027) decreased from pre- to post-ITB. The threshold velocity significantly increased post-injection in both muscles (p ≤ 0.001) without significant changes in the threshold angle. The response magnitudes significantly decreased in the knee extensors (p ≤ 0.016) but not the knee flexors after the injection.

CONCLUSIONS

The prevalence and threshold velocity of SRR emerged as the most robust and practical parameters for assessing hyperreflexia during ITB bolus trial that can complement clinical assessment of muscle hypertonia.

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.

Inherited Ataxia and Intrathecal Baclofen for the Treatment of Spasticity and Painful Spasms

BACKGROUND

Intrathecal baclofen (ITB) treatment is considered a powerful tool in the management of severe spasticity in neurological conditions such as multiple sclerosis, cerebral palsy, and traumatic spinal cord and brain injury.

OBJECTIVES

The objective of this study was to assess the effectiveness of the ITB in patients with inherited ataxia suffering from severe painful spasms and/or spasticity.

METHOD

A total of 5 patients with spinocerebellar ataxia 3 or 7 or Friedreich's ataxia were included in this observational multicenter study. The patients were interviewed and completed outcome measures assessing pain (The Brief Pain Inventory), fatigue (Fatigue Severity Scale), and life satisfaction (LiSAT-9) before and 1 year after the treatment. Spasticity (Modified Ashworth Scale) and spasm frequency (SPFS) were measured objectively for each patient.

RESULTS

The mean treatment time was 1.9 years. Evaluation of established standard forms revealed symptomatic relief from spasticity, spasms, pain, and fatigue in addition to improved body posture, sleep, and life satisfaction after ITB treatment.

CONCLUSIONS

We report the potential beneficial effects of ITB treatment in patients with inherited ataxia who also suffer from spasticity/spasms. ITB treatment indication in neurological disorders allows for extension to the treatment of spasticity/ spasms in patients with hereditary ataxia.

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.

The effect of continuous intrathecal baclofen therapy on ambulatory children with cerebral palsy

The effect of a continuous intrathecal infusion of baclofen (CITB) was retrospectively studied in 19 ambulatory children with cerebral palsy (aged 12.4±4.9 years at CITB initiation). The mean clinical follow-up was 5.1±2.4 years and the mean follow-up gait analysis was 2.8±1.9 years. Spastic cerebral palsy diagnosis [14 (74%)] was most frequent. Most patients [11 (58%)] were Gross Motor Function Classification System level III. CITB significantly improved muscle tone and knee flexion at initial contact (P<0.05), but it did not lead to improved gait speed or gross motor function.

Differences in driving performance due to headway distances and gender: the application of jerk cost function

Driving is directly controlled by the driver's movement. This study tried to compare differences in gender and headway distances between the DRIVING phase and the SUDDEN STOP phase by using subjects' movement during driving in the simulator. To quantify subjects' movement, the jerk cost function (JC) was used, and conventional vehicle control parameters such as the coefficient of variation of the mediolateral trajectory (MLCV) for lane keeping and the brake time (BT) were also used. As the headway distance increased, MLCV and JC decreased significantly in the DRIVING phase. In the SUDDEN STOP phase, BT was increased and, MLCV and JC were decreased. Differences between genders were detected for both MLCV (males < females) and JC (males > females). The results of this study demonstrate that JC may be used as a variable in evaluating driving performance as influenced by driving conditions and gender.

Relationship between activation of ankle muscles and quasi-joint stiffness in early and middle stances during gait in patients with hemiparesis

It is unclear whether muscle contraction is necessary to increase quasi-joint stiffness (QJS) of the ankle joint during gait in patients with hemiparesis. The purpose of the present study was to investigate the relationship between QJS and muscle activation at the ankle joint in the stance phase during gait in patients with hemiparesis. Spatiotemporal and kinetic gait parameters and activation of the medial head of the gastrocnemius (MG), soleus (SOL), and tibialis anterior (TA) muscles were measured using a 3-dimensional motion analysis system and surface electromyography, in 21 patients with hemiparesis due to stroke and 10 healthy individuals. In the early stance, the QJS on the paretic side (PS) of patients was greater than that on the non-PS (p<0.05) and not significantly correlated with activation of the three muscles. In the middle stance, the QJS on the PS was lower than that on the non-PS (p<0.05) and that on the right side of controls (p<0.001), which was positively correlated with activation of the MG (r=0.51, p<0.05) and SOL (r=0.49, p<0.05). In the patients with hemiparesis, plantarflexor activation may not contribute to QJS in the early stance. On the other hand, QJS in the middle stance may be attributed to activation of the MG and SOL. Our findings suggest that activation of the MG and SOL in the middle stance on the PS may require to be enhanced to increase QJS during gait in patients with hemiparesis.

Effect of the Intrathecal Baclofen Screening Test on the Spatiotemporal Gait Motion Parameters of Patients with Cervical Spinal Cord Injuries Who Exhibited Diffuse Spasticity: A Report of Three Cases

We examine the quantitative changes in the gait motion of patients with cervical spinal cord injuries (CSCIs) before and after the intrathecal baclofen (ITB) screening test. The subjects were three patients with CSCI, who exhibited spasticity in the lower extremities. They could all walk 10 or more meters with/without aids. All patients were subjected to the ITB screening test, in which they had gabalon (50 μg) injected into their spinal column via paramedian puncture at the L3–4 level. The subjects had their ankle clonus; patellar tendon reflex; and modified Ashworth scale, Berg balance scale, Spinal Cord Independence Measure, and 10 -meter walk test (10MWT) assessed before and 5 hours after the ITB screening test. At 5 hours after the ITB screening test, all of the patients exhibited decreased spasticity in static position, and improved balance. There were no differences in the abilities of any of the patients to perform ADL. One patient did not change the spatiotemporal gait motion parameters (walking time, step count, and step length in the 10MW T). Therefore, the pomp implantation for ITB therapy was not performed. Two patients who had suffered CSCI more than 20 years ago exhibited a reduced walking time, increased step count, and step length. Out of the two patients one received the pomp of implantation after ITB screening test, and the other was planned to operate. The spatiotemporal gait motion parameters might be one of the useful tests to decide the pomp implantation for CSCI patients who hope improvement of gait ability.

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.

Driving performance changes of middle-aged experienced taxi drivers due to distraction tasks during unexpected situations

This study investigated the effects of distraction taskssuch as sending a text message with a cellphone and searching navigation with car navigation system-on the driving performance of 29 highly experienced taxi drivers in their 50s. All participants were instructed to drive using a driving simulator for 2 min. while maintaining a constant distance from the vehicle in front and a constant speed. Participants drove without any distractions for the first minute. For an additional minute, they performed Driving Only or performed a task while driving (Driving + Sending Text Message or Driving + Searching Navigation). An unexpected situation, in which the participant had to stop abruptly due to a sudden stop of the preceding vehicle, occurred during this period. Driving performance during the unexpected situation was evaluated by car control variables, medial-lateral coefficient of variation and brake time, and by motion variables such as the jerk-cost function. Compared to Driving Only, jerk-cost function, medial-lateral coefficient of variation, and brake time increased during Driving + Sending Text Message or Driving + Searching Navigation.

The effects of disruption in attention on driving performance patterns: analysis of jerk-cost function and vehicle control data

This study analyzes the effects of attention disruption factors, such as sending text messages (STM) and performing searching navigation (SN) on driving performance patterns while actively driving, centering on motion signals. To this end, it analyzes not only data on control of the vehicle including the Anterior-Posterior Coefficient of Variation (APCV), Medial-Lateral Coefficient of Variation (MLCV), and Deviation of Vehicle Speed but also motion data such as the Jerk-Cost function (JC). A total of 55 drivers including 28 males (age: 24.1 ± 1.5, driving experience: 1.8 years ± 1.7 years) and 27 females (age: 23.8 ± 2.6, driving experience: 1.5 ± 1.0) participated in this study. All subjects were instructed to drive at a constant speed (90 km/h) for 2 min while keeping a distance of 30 m from the front car also running at a speed of 90 km/h. They were requested to drive for the first 1 min and then drive only (Driving Only) or conduct tasks while driving for the subsequent 1 min (Driving + STM or Driving + SN). The information on APCV, MLCV, and deviation of speed were delivered by a driving simulator. Furthermore, the motion signal was measured using 4 high-speed infrared cameras and based on the measurement results, JCs in a total of 6 parts including left shoulder (L.shoulder), left elbow (L.elbow), left hand (L.hand), right knee (R.knee), right ankle (R.ankle), and right toe (R.toe) were calculated. Differences among the results of 3 conditions of experiment, Driving Only, Driving + STM, and Driving + SN, were compared and analyzed in terms of APCV, MLCV, Deviation of Vehicle Speed, and JC. APCV and Deviation of Vehicle Speed increased in Driving + SN, rather than in Driving Only. MLCV increased in Driving + STM and Driving + SN, rather than in Driving Only. In the case of most JCs except that of L.hand, the values increased in Driving + SN, compared to Driving Only. This study indicated that JC could be a reliable parameter for the evaluation of driving performance patterns. In addition, it was discovered that additional tasks under driving, such as STM and SN, impaired smoothness or proficiency in driving motion, thereby increasing anterior-posterior and medio-lateral variability and deviation of speed.

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.

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.

New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy

Cerebral palsy (CP) is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations. This article focuses on current and future intervention strategies for improving mobility and participation during the lifespan for ambulatory children with CP. The provision and integration of physical therapy and medical and orthopedic surgery management focused primarily on the lower extremities are discussed here. Some of the newer trends are more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who face a lifelong disability with unique challenges at each stage in life.

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.

Repeatability of lower limb three-dimensional kinematics in patients with stroke

The within- and between-session repeatability of time-distance and sagittal plane kinematic gait parameters were evaluated in 20 hemiparetic patients with sub-acute stroke. A test-retest design was used in which the patients were tested during two sessions within a 2h period. Each session comprised three consecutive trials. The intraclass correlation coefficients (ICCs) for time-distance parameters ranged from 0.82 to 0.99. The within- and between-session repeatability of pelvis, hip, knee and ankle kinematic waveforms were high: the mean coefficient of multiple correlations (CMCs) ranged from 0.85 to 0.95. The within-session coefficient of variation (CV%) for time-distance parameters ranged from 3.9 to 14.1, whereas, between-session CV% ranged from 6.1 to 17.2, showing similar but higher variability. The within- and between-session CV% for sagittal plane kinematics of the paretic lower limb ranged from 3.6 to 32.4. The results indicate that time-distance parameters and sagittal plane gait kinematics of the paretic lower limb, measured by the Vicon 370 gait analysis system, are repeatable and can be used to assess treatment effects after stroke.

Intrathecal baclofen in the treatment of spasticity, dystonia and vegetative disorders

Baclofen (beta-p-chlorophenyl-GABA) binds to a number of spinal and cerebral sites and depresses the excitability of motor neurons. Intrathecal administration induces much higher CSF concentrations compared to the limited passage through the blood-brain barrier after oral administration. The development of reliable implanted pumps allows long-term intrathecal baclofen treatment (ITB). Baclofen is mainly an antispastic drug and the main indication of ITB is generalized lower limb spasticity in spinal cord injury and multiple sclerosis. The side-effects are due to either drug over-dose or withdrawal and to malfunctions of the implanted device (disconnections of the catheter, infections, etc.). Large numbers of patients have been treated over the past twenty years. More recently, baclofen has been used in the treatment of spasticity of cerebral origin, and in the treatment of other motor disorders, mainly dystonia. The results in cerebral palsy are promising and ITB's role will probably grow in the management of the movement disorders of these children. Further studies are required on the exact site of action, on the possible association with other drugs, especially clonidine and on the development of sustained release formulations.

Prolonged quadriceps activity following imposed hip extension: a neurophysiological mechanism for stiff-knee gait?

The biomechanical characteristics of stiff knee gait following neurological injury include decreased knee flexion velocity at toe-off, which may be due to exaggerated quadriceps activity. The neuromuscular mechanism underlying this abnormal activity is unclear, although hyperexcitable heteronymous reflexes may be a source of impaired coordination. The present study examines the contribution of reflex activity from hip flexors on knee extensors following stroke and its association with reduced swing-phase knee flexion during walking. Twelve individuals poststroke and six control subjects were positioned in supine on a Biodex dynamometer with the ankle and knee held in a static position. Isolated hip extension movements were imposed at 60, 90, and 120 degrees /s through a 50 degrees excursion to end-range hip extension. Reflexive responses of the rectus femoris (RF), vastus lateralis (VL), and vastus medialis (VM) were quantified during and after the imposed hip rotation. Gait analysis was also performed for all subjects in the stroke group. In subjects with stroke, imposed hip extension evoked a brief reflexive response in the quadriceps, followed by a heightened level of sustained activity. The initial response was velocity dependent and was larger in the stroke group than in the control group. In contrast, the prolonged response was not velocity dependent, was significantly greater in the VL and RF in subjects with stroke, and, importantly, was correlated to decreased swing-phase knee flexion. Hyperexcitable heteronymous connections from hip flexors to knee extensors appear to elicit prolonged quadriceps activity and may contribute to altered swing-phase knee kinematics following stroke.

Efficacy of intrathecal baclofen delivery in the management of severe spasticity in upper motor neuron syndrome

In the treatment of patients with severe spasticity, intrathecal administration of baclofen (ITB) was introduced in order to exert its effect directly at the receptor sites in the spinal cord, and have better therapeutic efficacy with smaller drug doses compared to oral antispasmodic medications. Apart from our own research in Groningen, a review is performed to present and discuss the efficacy of ITB in patients with spasticity and hypertonia as symptoms of the upper motor neuron syndromes. The majority of the ITB studies describe proven efficacy in the reduction of spasticity and spasms in short-term and long-term follow-up. Functional improvements in daily care, hygiene, pain, etc are described but not often with reliable and validated instruments. A few studies reported significant improvement in walking performance in ambulant patients. The studies that have been done on the efficacy of ITB in relation to quality of life (QOL) showed some evidence of improvement. Future research is needed on fine tuning in the ITB therapy using functional assessment instruments.

Intrathecal baclofen for childhood hypertonia

INTRODUCTION

Intrathecal baclofen was first introduced in 1985 to manage childhood hypertonia. There has been an evolution in thought as to how candidates should be identified and what forms of hypertonia respond to this treatment.

PURPOSE

This manuscript reviews the pharmacology of the drug, the assessment of candidates, the implantation of the infusion pump, and the usual doses delivered. Side effects and complications are reviewed as are outcomes.

Intrathecal baclofen therapy: indications, pharmacology, surgical implant, and efficacy

Intrathecal baclofen (ITB) therapy is an option for those in whom predominantly lower extremity spasticity is severe, problematic, and intractable to oral doses of medications and/or focal treatment. When delivered to the lumbar area, ITB avoids high concentrations from reaching the brain (4:1 ratio lumbar to brain cisterns). A screening test dose is done prior to implanting the pump via a lumbar puncture with 50 microg baclofen, working up to 100 microg if necessary. There are two [2] types of pumps. The electronic programmable type has the advantage of flexibility of dosing and frequent change of doses for fine-tuning the patient's optimal dose. The mechanical constant flow type has the advantages of (1) being gas driven and not needing battery replacement, and (2) not needing a programmer to refill, thus allowing geographically removed patients to benefit from ITB. Catheter complications are reduced by using a shallow-angle paramedian oblique insertion to the spine, and meticulous anchoring of the catheter. Threading the catheter to T6/7 rather than the traditional T10/11 can allow upper limb relief also. Long term efficacy is excellent, although catheter complications are frequent. and if not recognized and treated, can lead to significant effects of withdrawal of baclofen.

Intrathecal baclofen in current neuromodulatory practice: established indications and emerging applications

Intrathecal baclofen (ITB) has evolved into a standard treatment for severe spasticity of both spinal and cerebral origin. The accumulated promising data from reported series of patients receiving ITB therapy together with the fact that spastic hypertonia commonly coexists with other neurological disorders have constituted a solid basis for offering this kind of treatment to patients suffering from other movement disorders. These include motor disorders such as dystonia, amyotrophic lateral sclerosis, status dystonicus, Hallervorden-Spatz disease, Freidreich's ataxia, "stiff-man" syndrome, but also vegetative states after revere brain trauma, anoxic encephalopathy or other pathology and more recently, various chronic pain syndromes. In this article, on the basis of the established applications of ITB therapy, we review the important emerging indications of this rewarding neuromodulation method and attempt to identify its future potential beneficial role in other chronic and otherwise refractory neurological disorders.

Intérêt de la pompe à baclofène dans le traitement de la spasticité chez l'hémiplégique: à propos d'un cas

OBJECTIVE

To determine whether intrathecal administration of baclofen reduced spastic hypertonia in a hemiplegic patient after hemorrhagic stroke.

METHODS

A trial of intrathecal administration of baclofen was carried out with bolus injections of 50 and 75 microg baclofen and clinical and functional evaluation (Aschworth, articular amplitude) before and after injection in a patient with hemorrhagic stroke. After these trials, the placement of a pump was proposed to the patient.

RESULTS

Aschworth score improved from 4 to 3 on triceps, quadriceps and adductus, with functional improvement of gait quality and perimeter and position in the wheelchair. Cephalgia, present before the treatment, increased after the implantation of the pump. The patient had some ejaculation trouble with the treatment, as well as some neurological pains after the pump implantation but experienced no effect on upper limbs.

DISCUSSION

The intrathecal administration of baclofen has been used in some studies of hemiplegic patients, with reduced spasticity and improved the kinematic parameters of gait. The intrathecal baclofen administration could complement other treatment to control spasticity after stroke.

CONCLUSION

Intrathecal baclofen administration could be an interesting complementary therapeutic among patients with important spasticity not controlled by the usual treatments.

Consensus panel guidelines for the use of intrathecal baclofen therapy in poststroke spastic hypertonia

Intrathecal baclofen (ITB) therapy has been increasingly employed for the management of poststroke spastic hypertonia, a complication that can lead to deformity, discomfort, and exacerbation of motor impairments. Because its use in stroke is not as established as other indications, ITB therapy has not been subjected to rigorous investigation. There is limited evidence to guide clinicians regarding application of this therapy in this patient population. This article aims to review the available scientific literature and the opinion of several experts on the topic. It will also describe the recommendations of these experts with regard to addressing common clinical situations that may influence treatment decisions in the stroke population.

Intrathecal baclofen in the management of post-stroke hypertonia: current applications and future directions

This chapter will review the application of intrathecal baclofen (ITB) in the management of post-stroke hypertonia, a major complication that results in deformity and discomfort, and limits mobility and performance of activities of daily living (ADL). Initially, ITB was considered only in conditions characterized by severe multi-limb spastic hypertonia in non-ambulatory individuals. Lately, ITB is used in persons with stroke who can ambulate, with the intent of further improving walking ability. Early clinical experience and evidence suggest that when used in the appropriate patient, ITB is efficacious and safe in managing post-stroke hypertonia in individuals of various functional levels. This chapter will also review clinical situations that are common in the stroke population, which may influence treatment decision choices. There are still ample opportunities to conduct research on this treatment modality, especially in the areas of patient selection and outcomes in the stroke population.

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

OBJECTIVES

To evaluate the impact of intrathecal baclofen (ITB) on function and quality of life (QOL) and to obtain efficacy and safety data in poststroke spastic hypertonia.

DESIGN

Prospective open-label multicenter trial with follow-up at 3 and 12 months.

SETTING

Twenty-four stroke treatment centers in the United States.

PARTICIPANTS

Ninety-four stroke participants (age range, 24-82 y) with spastic hypertonia. Seventy-four participants underwent ITB pump implantation.

INTERVENTION

Participants were implanted with an ITB pump.

MAIN OUTCOME MEASURES

FIM instrument and QOL (Sickness Impact Profile [SIP]) changes, spastic hypertonia (Ashworth Scale), and safety.

RESULTS

FIM scores improved overall in repeated-measures analysis of variance (ANOVA) (P = .005) and by 3.00 +/- 7.69 (P = .001) at 3 months and by 2.86 +/- 10.13 (P = .017) at 12 months. Significant improvements in SIP scores were noted overall (repeated-measures ANOVA, P < .001) and at 3 (P = .003) and 12 months (P < .001). The combined average Ashworth Scale score of the upper and lower limbs decreased by 1.27 +/- 0.76 (P < .001) at 3 months and by 1.39 +/- 0.73 (P < .001) at 12 months from baseline, which was significant overall (repeated-measures ANOVA, P<.001). Strength in the unaffected side did not change overall (repeated-measures ANOVA, P = .321) or at either 3 (P = .553) or 12 months (P = .462). Minimal adverse events and device complications were reported.

CONCLUSIONS

There was significant improvement in function, QOL, and spastic hypertonia at 3 and 12 months after implant, without adversely affecting muscle strength of the unaffected limbs. Data suggest that ITB therapy is a safe and efficacious treatment for spastic hypertonia resulting from stroke.

Biomechanical measurement of post-stroke spasticity

BACKGROUND

spasticity following stroke is common, but clinical measurement is difficult and inaccurate. The most common measure is the modified Ashworth scale (MAS) which grades resistance to passive movement (RPM), but its validity is unclear.

AIM

to assess the validity of the MAS.

METHODS

spasticity was clinically graded using MAS and RPM measured biomechanically in the impaired arm of 111 patients following stroke. The biomechanical device measured RPM, applied force, angular displacement, mean velocity, passive range of movement (PROM) and time required.

RESULTS

the median age was 72 years, and 66 subjects were male. The clinical grading by MAS was '0' in 15, '1' in 15, '1+' in 14, '2' in 13, '3' in 43 and '4' in 11. There was no difference in RPM among '0', '1', '1+' and '2' (P > 0.1). However, grade'4' was higher than '3' and below (P < 0.05). The force required increased with the increasing MAS while velocity and PROM decreased (P < 0.01). We regrouped the data using the algorithm: no stiffness = '0'; mild = '1' and '1+' and '2'; moderate = '3'; severe = '4'. There was no difference between 'no stiffness' and 'mild ' (P > 0.10), but 'mild' and moderate' as well as 'moderate' and 'severe' were different (P < 0.01).

CONCLUSION

the MAS is not a valid ordinal level measure of RPM or spasticity. Objective measurement of RPM is possible in the clinical setting. However, additional measurements of muscle activity (electromyography) will be required to quantify spasticity.

Experimental protocol for the kinematic analysis of the hand: definition and repeatability

A quantitative and objective method based on the optoelectronic kinematic analysis of hand segments and on the calculation of global and partial parameters, which provide measures of the degree of long finger and thumb extension is proposed for the evaluation of the hand's voluntary range of motion and maximal opening of the fingers and thumb. To test the precision and repeatability of the method, the protocol was applied on 14 healthy subjects (28 hands). The proposed parameters are repeatable and show a precision between 5.5 degrees and 10.4 degrees (mean value: 7.3 degrees), comparable to values obtained with other methods. Advantages of the present approach include simultaneous analysis of all fingers, absence of cumbersome connecting cables and no need for individually customized devices. The method, also applied to the paretic hands of two hemiplegic stroke patients before and after electrical stimulation of the wrist and finger extensor muscles, has shown encouraging results for its clinical feasibility and utility in addition to functional tests.

Identification of intrinsic and reflex ankle stiffness components in stroke patients

Reflex and intrinsic contributions to ankle stiffness were examined in 11 stroke patients with clinical evidence of ankle spasticity and nine gender-matched and age-matched controls. Subjects lay supine with one foot placed in a custom-fitted boot attached to an electro-hydraulic actuator. They were instructed to relax while pseudo-random binary sequence perturbations were applied to their ankle joint. The ankle position and torque, as well as EMG from the ankle dorsiflexors and plantarflexors were recorded. These were used to identify reflex and intrinsic components of ankle stiffness, using a non-linear, parallel-cascade, system identification method. Results demonstrated that the majority of stroke patients (7/11) had ankle stiffness similar to that of control subjects. In contrast, a minority of stroke patients (4/11) had an abnormal increase in ankle stiffness, most of which could be attributed to an increased reflex gain. Reflex stiffness increased as the ankle was dorsiflexed in all subjects. These results differ from a previous study showing that reflex gain and intrinsic stiffness were increased in all patients with spinal cord injury. This difference may reflect the different topography of the lesions in the two neurological conditions.

Effect of Intrathecal Baclofen Bolus Injection on Temporospatial Gait Characteristics in Patients With Acquired Brain Injury

OBJECTIVE

To evaluate changes in temporospatial gait parameters after intrathecal baclofen (ITB) bolus administration in patients with spasticity resulting from acquired brain injury by using computerized gait analysis.

DESIGN

Case series; before-after intervention. Walking performance and spasticity in lower-extremity muscles were assessed before and at 2, 4, and 6 hours after ITB bolus injection.

SETTING

Tertiary care free-standing rehabilitation hospital.

PARTICIPANTS

Consecutive sample of 28 adults with acquired brain injury due to stroke, trauma, or anoxia.

INTERVENTION

A 50-microg ITB bolus injection (2 subjects received 75 microg and 100 microg, respectively).

MAIN OUTCOME MEASURES

Ashworth Scale scores, self-selected gait velocity, stride length, cadence, step length symmetry, step width, and percentage of single support on the more involved side.

RESULTS

Ashworth score decreased from 2.0+/-0.5 at baseline to 1.3+/-0.3 at peak response ( P <.001), whereas gait velocity increased from 41+/-26 to 47+/-31 cm/s ( P <.001). Significant improvements also occurred in stride length ( P <.05) and step width ( P <.001). Gait velocity was the most sensitive temporospatial outcome measure for differentiating functional response to ITB bolus injection. Sixteen patients increased velocity by an average of 12 cm/s, representing a mean gain of 33% over their baseline walking speed, while 5 decreased (mean loss, -6 cm/s [52% of baseline]) and 7 were unchanged. There was a significant correlation between baseline velocity and peak change in velocity after ITB bolus ( r =.39, P <.05). Baseline Ashworth score correlated inversely with velocity, stride length, cadence, and percentage single support (r range, -.46 to -.57). No significant correlations were found between change in Ashworth score and change in any temporospatial outcome measure.

CONCLUSIONS

ITB bolus injection consistently reduces spasticity in ambulatory patients with acquired brain injury but may result in a range of changes in walking performance that can be reliably detected using computerized motion analysis. Velocity appears to be the most sensitive parameter with which to classify individual patient response. The relation between baseline gait velocity and peak change in velocity after bolus administration may have application in predicting the outcome of screening trials for pump implantation; it warrants further investigation.

Instrumental Evaluation of Gait Modifications Before and During Intrathecal Baclofen Therapy

Intrathecal baclofen therapy has been used for several years, despite the fact that long-term gait modifications in ambulatory patients have not been thoroughly investigated. A 31-yr-old male patient affected by hereditary spastic paraparesis was evaluated clinically and by gait analysis. Evaluations were made before and at 6, 12, 16, and 24 mos after implantation. The patient showed a clear improvement in self-selected speed, step and stride length, knee and ankle kinematics, and ankle kinetics. Moreover, the response observed on self-selected speed is consistent with the intrathecal baclofen dose administered. To our knowledge, this is the first report of a long-term instrumental gait analysis assessment of a patient receiving intrathecal baclofen. Gait analysis could be a reliable and feasible assessment tool to evaluate ambulatory patients receiving intrathecal baclofen therapy over time and to help clinicians in determining exact dose requirements.

Stroke and neurodegenerative disorders. 3. stroke: rehabilitation management11An organization with which one or more of the authors is associated has received or will receive financial benefits from a commercial party having a direct financial interest in the results of the research supporting this article. Geis is on the advisory board and the speaker’s bureau of Allergan; she is on the speaker’s bureau of Medtronic

This self-directed learning module highlights common rehabilitation issues in stroke survivors. Topics include spasticity, constraint-induced movement therapy, partial body weight-supported treadmill training, virtual reality training, vestibular retraining, aphasia treatment, and cognitive retraining. It is part of the study chapter on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVES

(a) To identify and review the treatment options for poststroke spasticity; (b) to review the use of body weight-supported treadmill training in stroke patients; (c) to describe virtual reality training as an adjunct in stroke rehabilitation; (d) to review vestibular rehabilitation; (e) to discuss advances in aphasia treatment; (f) to discuss cognitive retraining; and (g) to provide an update on treatment of neglect syndromes.