Mechanisms, Measurement, and Management of Spastic Hypertonia after Head Injury

Continuously infused intrathecal baclofen over 12 months for spastic hypertonia in adolescents and adults with cerebral palsy

OBJECTIVE

To determine if the continuous intrathecal delivery of baclofen will control spastic hypertonia caused by long-standing cerebral palsy (CP).

DESIGN

Case series.

SETTING

Tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital.

PATIENTS

Thirteen CP patients (average age, 25yr; range, 13--43yr) with intractable spastic hypertonia and quadriparesis (one of whom had predominate diplegia) who had not responded to oral medications including baclofen.

INTERVENTION

Patients were screened via a bolus injection of baclofen intrathecally. Those who dropped an average of 2 points on their lower extremity (LE) Ashworth scores were offered computer-controlled pump implantation for 12 months of continuous delivery of intrathecal baclofen (ITB).

MAIN OUTCOME MEASURES

Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UEs) and LEs. Differences over time were assessed via descriptive statistics and Wilcoxon's signed-rank test.

RESULTS

After 1 year of continuous ITB treatment, the average LE Ashworth score +/- standard deviation decreased from 3.4 +/- 1.2 to 1.5 +/- 0.7 (p <.0001), spasm score from 1.4 +/- 1.6 to 0.6 +/- 1.2 (p =.1024), and reflex score from 2.5 +/- 1.2 to 0.7 +/- 1.1 (p <.0001). The average UE Ashworth score decreased from 3.0 +/- 1.2 to 1.7 +/- 1.0 (p <.0001), spasm score from 1.2 +/- 1.6 to 0.2 +/- 0.6 (p =.0135), and reflex score from 2.3 +/- 0.7 to 0.5 +/- 0.9 (p <.0001). The average ITB dose required to attain these effects at 1 year was 263 +/- 91microg continuously infused per day.

CONCLUSION

Continuously infused ITB can reduce spastic hypertonia in the UEs and LEs associated with long-standing CP. This reduction in tone will allow more freedom of movement and the potential for improved function.

Treatment of cerebral origin spasticity with continuous intrathecal baclofen delivered via an implantable pump: long-term follow-up review of 18 patients

OBJECT

The goal of this study was to assess the long-term benefits of managing severe spasticity by using continuous infusion of intrathecal baclofen delivered via an implantable pump.

METHODS

Eighteen patients with severe spasticity of cerebral origin, who failed to respond adequately to more conservative treatments, have-been treated with continuous infusion of intrathecal baclofen delivered via an implanted pump. Follow-up review of these patients has lasted between 12 months and 9 years. The patients have been assessed using a variety of tools. Seventeen have had a significant reduction in tone and all have benefited by a reduced need for nursing care or increased function or both.

CONCLUSION

Long-term continuous infusion of intrathecal baclofen delivered via an implantable pump offers an effective method for dealing with otherwise intractable spasticity.

Long-term continuously infused intrathecal baclofen for spastic-dystonic hypertonia in traumatic brain injury: 1-year experience

OBJECTIVE

To determine if the long-term use of continuously infused intrathecal baclofen (ITB) over a 1-year period will control spastic-dystonic hypertonia in patients with traumatic brain injury (TBI).

SETTING

Tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital.

SUBJECTS

Persons with TBI and intractable spasticity and dystonia for more than 6 months' duration recruited in a consecutive manner.

DESIGN

TBI patients were admitted to the study after screening via a bolus injection of either intrathecal normal saline or 50 microg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Patients whose LE Ashworth scores decreased an average of 2 points were then offered implantation of a computer-controlled pump for continuous ITB. Changes over time were assessed statistically via Friedman's analysis for ordinal data and ANOVA for linear data. Differences between set points in time were also assessed via Wilcoxon signed rank.

DATA SET

Seventeen patients (average age 29+/-11 yrs) with spasticity and/or dystonia treated over 1 year via a computer-controllable intrathecal delivery system for the delivery of ITB.

RESULTS

After 1 year of continuous ITB treatment the average LE Ashworth score decreased from 3.5+/-1.3 (SD) to 1.7+/-0.9 (p < .0001), spasm score from 1.8+/-1.3 to 0.2+/-0.5 (p< .0001), and reflex score from 2.5+/-1.1 to 0.1+/-0.3 (p < .0001). The average UE Ashworth score decreased from 2.9+/-1.5 to 1.6+/-1.0 (p < .0001), spasm score from 1.2+/-1.5 to 0.2+/-0.6 (p < 0.0001), and reflex score from 2.2+/-0.5 to 1.0+/-0.8 (p < .0001). The average ITB dose required to attain these effects at 1 year was 302 microg continuously infused per day.

CONCLUSION

Continuous intrathecal infusion of baclofen is capable of maintaining a reduction in spasticity and dystonia in both the upper and lower extremities of TBI patients.

Prospective study on the use of bolus intrathecal baclofen for spastic hypertonia due to acquired brain injury

OBJECTIVE

To determine if the intrathecal delivery of baclofen will decrease spastic hypertonia caused by brain injury.

PATIENTS

Eleven patients more than 1 year after their brain injury with disabling lower extremity spastic hypertonia.

SETTING

University tertiary care outpatient rehabilitation clinic.

DESIGN

Patients were a consecutive sample randomized in a double blind, placebo-controlled crossover study.

INTERVENTIONS

Bolus intrathecal injection of either normal saline or 50 micrograms baclofen.

MAIN OUTCOME MEASURES

Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Changes over time were assessed via Friedman's test. Differences between the placebo and active drug at any given time were assessed via Wilcoxon signed-rank.

RESULTS

Four hours after injection with the active drug (maximum effect) the average LE Ashworth score decreased from 4.2 +/- 0.8 (SD) to 2.2 +/- 0.6 (p = .0033), spasm score from 3.1 +/- 1.0 to 1.0 +/- 0.7 (p = .0032), and reflex score from 3.3 +/- 0.5 to 1.0 +/- 1.3 (p = .0033). The average UE Ashworth score decreased from 3.3 +/- 1.3 to 1.9 +/- 0.8 (p = .0033), spasm score from 1.8 +/- 1.3 to 0.6 +/- 1.0 (p = .007), and reflex score from 2.7 +/- 0.5 to 1.7 +/- 0.6 (p = .0111). No trend was observed over time with placebo administration. There were significant reductions in the average for LE Ashworth (p < .0001), spasm (p < .0001), and reflex (p < .0001) scores and for UE Ashworth (p < .0001) and spasm (p < .0004) scores observed over 4 hours (maximum effect) with active drug administration. No significant differences were noted between the active drug and placebo groups before administration in LE and UE Ashworth, spasm, or reflex scores. There were significant differences between the active drug and placebo groups at 4 hours after administration for LE and UE Ashworth, spasm, and reflex scores (p < or = .0272).

CONCLUSION

Intrathecal injection of baclofen is capable of reducing the spastic hypertonia associated with brain injury.