Outcomes of intrathecal baclofen therapy in patients with cerebral palsy and acquired brain injury

Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis

BACKGROUND

Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy.

METHODS

We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model.

RESULTS

We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported.

CONCLUSION

Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.

Evaluating Community-Based Intrathecal Baclofen Therapy: Effectiveness, Safety, and Feasibility

Background: Intrathecal baclofen (ITB) is used for the treatment of intractable spasticity. The burden of traveling for ITB screening and aftercare is problematic for nursing home residents with severe spasticity and seems to result in undertreatment of spasticity. The aim of this study is to evaluate the effectiveness, safety, and feasibility of ITB for nursing home residents treated in their home, describing the selection phase, the initial trial of ITB, and aftercare up to 3 months after implantation of an ITB pump. Methods: This retrospective database study included immobile, adult nursing home residents with severe spasticity, referred to an Ambulatory Care Clinic between 2016 and 2021. When eligible, an ITB trial was performed by ITB experts in the nursing home. If a permanent pump was implanted, dose titration and aftercare were performed on location. Results: A total of 102 patients were referred; 80 underwent an ITB trial on location, and 94% improved significantly on the Modified Ashworth Scale and clonus scale pre-ITB trial versus post-ITB trial, as well as at 3 months post-implantation. There was a low incidence of adverse events, mostly procedure- and drug-related. Conclusions: This study indicates that selection, testing, and aftercare for ITB on location is effective and safe.

Case report: Intrathecal baclofen therapy improved gait pattern in a stroke patient with spastic dystonia

Background

Intrathecal baclofen (ITB) therapy, a viable alternative for unsuitable candidates of conventional spasticity medications, is a preferred method of administration over the oral route. Owing to its enhanced bioavailability, ITB ensures a more effective delivery at the target site.

Objective

There is a lack of conclusive evidence regarding the use of ITB treatment in managing ambulatory patients with spastic dystonia. Before ITB pump implantation, patients commonly undergo an ITB bolus injection trial to rule out potential adverse reactions and verify the therapeutic effects on hypertonic issues. In this report, we highlight a case of spastic dystonia, particularly focusing on an ambulatory patient who demonstrated significant improvement in both the modified Ashworth scale (MAS) score and gait pattern following the ITB injection trial.

Case report

This case report outlines the medical history of a 67-year-old male diagnosed with left-side hemiplegia and spastic dystonia, resulting from his second episode of intracranial hemorrhage in the right thalamus. An ITB injection trial was initiated because the patient was not suitable for continued botulinum toxin injections and oral medications. This was due to the persistent occurrence of spastic dystonia in both the upper and lower extremities. The patient underwent a four-day ITB injection trial with progressively increasing doses, resulting in improved MAS scores and gait parameters, including cadence, step length, step time, stride length, and stride time were increased. Particularly, kinematic gait analysis demonstrates a substantial improvement of increased knee flexion in the swing phase in stiff knee gait pattern. These findings indicated a gradual reduction in spasticity-related symptoms, signifying the positive effect of the ITB injection trial. The patient eventually received an ITB pump implantation.

Conclusion

In this post-stroke patient with spastic dystonia, ITB therapy has demonstrated effective and substantial management of spasticity, along with improvement in gait patterns.

Improving Upper Limb Spasticity in Patients with Stroke by Electroacupuncture Therapy: a Pre- and Post-Treatment Study

Background

: Post-stroke upper limb spasticity (PS-ULS) causes a decline in the quality of life of patients by reducing their ability to perform normal daily activities.

Objectives

: We performed pre- and post-treatment analyses of the changes in stroke patients with ULS following constant electroacupuncture therapy (EAT).

Methods

: Thirty patients with PS-ULS underwent 12 sessions of EAT over 4 weeks. After performing acupuncture therapy at four acupoints on the affected arm (LI11, LI10, LI4, and TE5), electrostimulation (60 Hz) was performed for 20 min. The modified Ashworth scale (MAS) and the Fugl-Meyer assessment of the upper extremity (FMA-UE) were measured as the outcome variables.

Results

: Following EAT, there was a significant decrease in the elbow MAS score (p < 0.001), a significant decrease in the wrist MAS score (p < 0.01), and a significant increase in the FMA-UE score (p < 0.001). Adverse events related to EAT were not reported.

Conclusion

: EAT decreased upper limb spasticity and improved functional recovery at the elbow and wrist. Large-scale and rigorous clinical trials are needed to verify the efficacy of EAT.

Intrathecal Baclofen Infusion Pump for the Treatment of Painful Spastic Hemiplegia: A Case Report

Painful spastic hemiplegia is a common sequel to a stroke in which patients rarely achieve optimal levels of pain control. Herein, we report the case of a 62-year-old woman with painful spasticity secondary to an ischemic stroke of 15 years' evolution who received multiple pharmacological treatments without reaching motor or pain management goals. After an adequate analgesic response to the intrathecal baclofen test, the placement of an electromechanical pump was decided, reaching an effective maintenance dose of 150 μg per day. Despite achieving partial improvement in spasticity, optimal pain remission was achieved.

Inhibitory Synaptic Influences on Developmental Motor Disorders

During development, GABA and glycine play major trophic and synaptic roles in the establishment of the neuromotor system. In this review, we summarise the formation, function and maturation of GABAergic and glycinergic synapses within neuromotor circuits during development. We take special care to discuss the differences in limb and respiratory neuromotor control. We then investigate the influences that GABAergic and glycinergic neurotransmission has on two major developmental neuromotor disorders: Rett syndrome and spastic cerebral palsy. We present these two syndromes in order to contrast the approaches to disease mechanism and therapy. While both conditions have motor dysfunctions at their core, one condition Rett syndrome, despite having myriad symptoms, has scientists focused on the breathing abnormalities and their alleviation-to great clinical advances. By contrast, cerebral palsy remains a scientific quagmire or poor definitions, no widely adopted model and a lack of therapeutic focus. We conclude that the sheer abundance of diversity of inhibitory neurotransmitter targets should provide hope for intractable conditions, particularly those that exhibit broad spectra of dysfunction-such as spastic cerebral palsy and Rett syndrome.

Intrathecal Baclofen and Opioid Therapy: Cerebrospinal Fluid Leak and Infection Incidence, Risk Factors, and Outcomes

BACKGROUND

Intrathecal drug therapy treats medically refractory spasticity and pain. cerebrospinal fluid (CSF) leak or infection can limit efficacy and increase morbidity. We aim to evaluate risk factors and outcomes after CSF leaks and infections requiring reoperation.

MATERIALS AND METHODS

We retrospectively analyzed our 7-year experience of intrathecal baclofen and opioid operations using a protocol designed to limit CSF leakage and infections. Postoperative complication incidence and risk factors for reoperation were compared with published reports. We assessed outcomes after these complications.

RESULTS

We analyzed 282 intrathecal baclofen (ITB) and intrathecal opioid (ITO) therapy operations (mean 2.27-year follow-up). 21% developed CSF leaks overall with similar incidences in ITB and ITO patients (19% vs. 25%, p0.3). Overall, 5% of patients developed deep infections with similar incidences between ITB and ITO cohorts (6% vs. 4%, p0.6). Tobacco use and age <50 years were significantly associated with CSF leak in ITO operations. Underweight body mass index, immunosuppression, tobacco use, and primary implantation were associated with infection. When CSF leak or infection occurred, patients suffered more perioperative adverse events and had elevated 90-day readmission rate compared with those without these complications.

CONCLUSIONS

Our 7-year ITB and ITO therapy using the 8781 Ascenda intrathecal catheter highlights a higher reoperation rate for CSF leak and similar infection incidence to reports using traditional catheters. Multiple modifiable risk factors for CSF leak include recent tobacco use among ITO patients. Body mass index optimization and immunosuppressant elimination may reduce reoperation for infection.

Efficacy and Safety of Subfascial Epidural Drainage Protocol After Intraoperative Durotomy in Posterior Thoracic and Lumbar Spine Surgery: Reoperation Prevention and Outcomes Among Drained and Undrained Cohorts

BACKGROUND

Persistent cerebrospinal fluid (CSF) egress after durotomy in posterior thoracic or lumbar spine surgery may cause devastating complications. Persistent CSF leaks may require reoperation, which confers additional cost and morbidity.

OBJECTIVE

To evaluate the efficacy of our subfascial epidural drainage protocol in the setting of durotomy to prevent reoperation.

METHODS

A retrospective cohort study of drained and undrained cohorts was completed to identify factors associated with reoperation for persistent CSF leak-related symptoms. The efficacy and safety of this 7-day subfascial epidural drainage protocol was assessed by comparing reoperation incidence, perioperative complications, rehabilitation necessity, and readmissions.

RESULTS

In total, 156 patients underwent subfascial epidural drainage, and 14 were not drained. Subfascial drainage for up to 7 days was associated with a significantly lower incidence of reoperation than no drainage (3.3% vs 14%, respectively; P = .03). Perioperative complication incidence was similar between cohorts (12.8% vs 21.4%, respectively; P = .37), and length of stay was unchanged regardless of drainage (median 7 days). Subfascial drainage conferred a nearly 2-fold relative risk reduction in inpatient rehabilitation requirement (RR 0.55) and 3-fold relative risk reduction in 30-day (RR 0.31) and 90-day readmission (RR 0.36). Factors associated with reoperation among drained patients included drainage longer than 7 days, tobacco use, age younger than 50 years, and longer segment operations. Revision spine surgery was associated with reoperation among undrained patients.

CONCLUSION

When followed after durotomy, our subfascial epidural drainage protocol results in fewer reoperations than in an undrained cohort without prohibitive cost and no added morbidity.

Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy

OBJECTIVE

In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options.

METHODS

The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes.

RESULTS

Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified.

CONCLUSIONS

Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.

Management of severe spasticity with and without dystonia with intrathecal baclofen in the pediatric population: a cross-sectional study

Objective

To investigate the differences in delivery mode, daily dose, and catheter tip location in pediatric patients using intrathecal baclofen (ITB) pumps with spasticity plus dystonia versus spasticity alone.

Methods

A single-center, cross-sectional study was performed by collecting retrospective data from electronic medical records. Demographic and diagnostic information was obtained, comparing patients with spasticity with or without dystonia. The data were analyzed for group differences using a two-tailed Student’s t-test. Categorical data were analyzed for group differences using Pearson’s χ2 test.

Results

A total of 137 patients met the criteria. The majority (114) had spasticity plus dystonia whereas only 23 were documented as spasticity alone. Simple continuous dosing was the most common delivery mode, but flex dosing was used more than twice as frequently with spasticity plus dystonia compared with spasticity alone (42% vs 17%). Patients with spasticity plus dystonia also had more rostral catheter tip locations.

Conclusions

While it has been discussed anecdotally, this study confirms the supposition that patients with spasticity plus dystonia have increased dose requirements when compared with those with spasticity alone. Although there are no clear standards of care when managing these patients, they are often on higher daily dosages, are more likely to require flexed dosing method, and have higher catheter placements. Still, there are few studies that demonstrate improvements in dystonia with the use of ITB. In general, these patients would benefit from the development of universal standardizations as well as the confirmation that this is an appropriate treatment.

Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity

BACKGROUND

Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses.

METHODS

Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded.

RESULTS

Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit.

CONCLUSION

ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.

Comprehensive Analysis of Trends in Medicare Utilization and Reimbursement in Physical Medicine & Rehabilitation: 2012 to 2017

INTRODUCTION

There is an absence of literature describing Medicare utilization by physiatrists, despite their key role in treating Medicare enrollees with qualifying disabilities and common neuromusculoskeletal conditions.

OBJECTIVE

Analyze Medicare data regarding physiatrists and their beneficiaries, services, and reimbursement, as well as trends in utilization and geographic distribution.

DESIGN AND SETTING

Retrospective analysis of publicly available Center for Medicare & Medicaid Services data for Medicare beneficiaries receiving physiatric services from 2012-2017.

MAIN OUTCOME MEASURES

After adjustment for inflation, variables assessed for changes over time included provider and beneficiary demographics, total Medicare reimbursement, and number of services provided, subsequently separated by drug and medical service metrics. Lorenz curves and Gini coefficients were computed to study reimbursement inequality. Choropleth maps were generated to assess geographic differences in physician density and reimbursement, both by state and ZIP code.

RESULTS

The number of physiatrists utilizing Medicare increased from 7230 to 7895 from 2012-2017, while the average number of unique beneficiaries per clinician remained constant (307 vs 310; P = 0.51). Beneficiaries' mean hierarchical conditions category (HCC) health risk score, normalized to 1.0 for the average beneficiary, increased significantly from 2012-2017 (1.72 vs 1.80; P < 0.01). Mean Medicare reimbursement per physiatrist decreased significantly from 2012-2017 ($131 960 vs $117 623; P < 0.001), while mean number of services remained constant (3243 vs 3077; P = 0.132). Botulinum toxin and baclofen injections were the two most reimbursed drug-related services. Gini coefficients ranged from 0.52-0.53 for 2012-2017, suggesting moderate reimbursement inequality, with the 75th percentile receiving on average 2 times the median. Both physician density and top earners were concentrated in urban and metropolitan areas.

CONCLUSIONS

Despite rising healthcare costs and increasing medical complexity of physiatrists' beneficiaries, Medicare payments have decreased over time. These trends are relevant to both providers and policy makers, particularly in light of unequal geographic distribution of physiatrists across the country. This article is protected by copyright. All rights reserved.

Baclofen therapeutics, toxicity, and withdrawal: A narrative review

Baclofen is an effective therapeutic for the treatment of spasticity related to multiple sclerosis, spinal cord injuries, and other spinal cord pathologies. It has been increasingly used off-label for the management of several disorders, including musculoskeletal pain, gastroesophageal reflux disease, and alcohol use disorder. Baclofen therapy is associated with potential complications, including life-threatening toxicity and withdrawal syndrome. These disorders require prompt recognition and a high index of suspicion. While these complications can develop following administration of either oral or intrathecal baclofen, the risk is greater with the intrathecal route. The management of baclofen toxicity is largely supportive while baclofen withdrawal syndrome is most effectively treated with re-initiation or supplementation of baclofen dosing. Administration of other pharmacologic adjuncts may be required to effectively treat associated withdrawal symptoms. This narrative review provides an overview of the historical and emerging uses of baclofen, offers practical dosing recommendations for both oral and intrathecal routes of administration, and reviews the diagnosis and management of both baclofen toxicity and withdrawal.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Caregiver-Reported Pain Management Practices for Individuals With Cerebral Palsy

Objective

To investigate types and intensity of pain experienced by individuals with cerebral palsy (CP) and common pain-relieving approaches used by caregivers.

Design

The approach was cross-sectional, using standardized interviews.

Setting

Individuals with CP were recruited from a specialty health care hospital.

Participants

Eighty-six individuals (N=86; mean age, 17.2 years; male, 58%) with CP and complex communication needs participated.

Interventions

Not applicable.

Main Outcome Measures

Pain type, mean pain intensity (MPI) (graded on a scale of 0=no pain to 10=worst possible pain), and mean pain relief (MPR) (graded on a scale of 0=intervention did not help at all to 10=intervention completely relieved pain) were assessed by caregiver report as part of the Dalhousie Pain Interview for each type of pain experienced in the previous 7 days.

Results

Caregivers reported that 58 participants (67%) had experienced pain in the previous 7 days. MPI was 7.7±1.8 when the pain was worst in the previous 7 days. The 2 most common types of pain included musculoskeletal pain (n=70) and gastrointestinal pain (n=11). The most frequent treatment to relieve musculoskeletal pain was changing positions (n=27, MPI=5.1±2.3, MPR=6.6±2.1), medication (n=25, MPI=7.4±1.6, MPR=5.3±1.9), and massage (n=19, MPI=6.7±1.9, MPR=5.2±1.7). To treat gastrointestinal pain, medication was typically used (n=4, MPI=4.8±1.4, MPR=5.5±1.0), although no treatment was just as common (n=4, MPI=4.5±2.3).

Conclusions

The results indicate that musculoskeletal pain is prevalent in individuals with CP, and changing physical positions and providing medication are strategies most used by caregivers.

Combination of acamprosate and baclofen (PXT864) as a potential new therapy for amyotrophic lateral sclerosis

There is currently no therapy impacting the course of amyotrophic lateral sclerosis (ALS). The only approved treatments are riluzole and edaravone, but their efficacy is modest and short‐lasting, highlighting the need for innovative therapies. We previously demonstrated the ability of PXT864, a combination of low doses of acamprosate and baclofen, to synergistically restore cellular and behavioral activity in Alzheimer's and Parkinson's disease models. The overlapping genetic, molecular, and cellular characteristics of these neurodegenerative diseases supported investigating the effectiveness of PXT864 in ALS. As neuromuscular junction (NMJ) alterations is a key feature of ALS, the effects of PXT864 in primary neuron‐muscle cocultures injured by glutamate were studied. PXT864 significantly and synergistically preserved NMJ and motoneuron integrity following glutamate excitotoxicity. PXT864 added to riluzole significantly improved such protection. PXT864 activity was then assessed in primary cultures of motoneurons derived from SOD1^G93A rat embryos. These motoneurons presented severe maturation defects that were significantly improved by PXT864. In this model, glutamate application induced an accumulation of TDP‐43 protein in the cytoplasm, a hallmark that was completely prevented by PXT864. The anti‐TDP‐43 aggregation effect was also confirmed in a cell line expressing TDP‐43 fused to GFP. These results demonstrate the value of PXT864 as a promising therapeutic strategy for the treatment of ALS.

Outcomes of Intrathecal Baclofen Therapy Compared With Deep Brain Stimulation in a Patient With Dystonic Cerebral Palsy: A Case Report

Deep brain stimulation (DBS) in internal globus pallidus is considered to be a good option for controlling generalized dystonia in patients with this condition. In this relation, it is known that DBS has already been shown to have significant effects on primary dystonia, but is seen as controversial in secondary dystonia including cerebral palsy (CP). On the other hand, intrathecal baclofen (ITB) has been known to reduce spasticity and dystonia in patients who did not respond to oral medications or botulinum toxin treatment. Here, we report a patient with dystonic CP, who received the ITB pump implantation long after the DBS and who noted remarkable improvement in the 36-Item Short Form Health Survey, Dystonia Rating Scale, Modified Barthel Index, and visual analog scale scores for pain after an ITB pump implantation was used as compared with DBS. To our knowledge, the present case report is the first to demonstrate the effects of an ITB pump on reducing pain and dystonia and improving quality of life and satisfaction, compared with DBS in a patient with CP.

CE: Managing Movement Disorders: A Clinical Review

: Neuromuscular disorders are complex, difficult both to differentiate and to manage. Yet nurses, who encounter a symptomatically diverse neuromuscular patient population in various practice settings, are expected to be well versed in managing the variable associated symptoms of these disorders. Here the authors discuss how to assess such neuromuscular conditions as muscle tightness, spasticity, and clonus; the pathophysiology underlying each; and the available recommended treatments, an understanding of which is necessary for successful symptom management and clear provider-patient communication.