Continuous intrathecal baclofen therapy in children with cerebral palsy - when does improvement emerge?

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.

Clinical course of pain intensity in individuals with cerebral palsy: A prognostic systematic review

AIM

To describe the clinical course of pain intensity in individuals with cerebral palsy (CP) resulting from usual care or specific interventions.

METHOD

We conducted an exploratory prognostic systematic review searching electronic databases from inception to 31st December 2021. Evidence from low and moderate risk-of-bias studies was synthesized.

RESULTS

We retrieved 2275 citations; 18 studies met the inclusion criteria and 10 were synthesized. The course of pain intensity in children with CP receiving usual care was stable over 15 weeks (χ² _[2]  = 1.8, p = 0.5). Children who received continuous intrathecal baclofen (CITB) reported significant pain intensity reduction (visual analogue scale [VAS] = -4.2 out of 10, 95% confidence interval [CI] = -6.3 to -2.1]) 6 months postinsertion but similar children receiving usual care had no significant change over 6 months (VAS = 1.3 out of 10, 95% CI = -1.3 to 3.6). Children receiving botulinum neurotoxin A (BoNT-A) injections had significant decreases in pain after 1 month (numeric rating scale = -6.5, 95% CI = -8.0 to -5.0). Adults with chronic pain receiving usual care reported stable pain intensity over time; pain intensity improved in ambulatory adults exercising and those treated surgically for cervical myelopathy.

INTERPRETATION

The course of pain intensity in individuals with CP is unclear. Evidence suggests that children and adults receiving usual care had stable pain intensity over the short or long term. Interventions (CITB and BoNT-A in children and exercise and surgical treatment for cervical myelopathy in adults) had pain intensity reduction. Larger study samples are needed to confirm these results.

WHAT THIS PAPER ADDS

Pain intensity was stable in children with cerebral palsy (CP) receiving usual care. Adults with CP and chronic pain receiving usual care had stable, persistent pain intensity. Children receiving continuous intrathecal baclofen via pump and botulinum neurotoxin A reported significantly lower pain intensities. Adults with chronic pain and dyskinetic CP and cervical myelopathy reported significantly lower pain intensity with exercise or cervical decompression. Limited high-quality evidence exists describing non-procedural pain changes in individuals with CP.

More Than Just Adolescence: Differences in Fatigue Between Youth With Cerebral Palsy and Typically Developing Peers

OBJECTIVE

To quantify differences in fatigue and disordered sleep between adolescents with cerebral palsy (CP) and their typically developing peers. A secondary aim was to investigate the association between fatigue and disordered sleep in adolescents with CP.

METHODS

A convenience sample of 36 youth with CP aged 10-18 years was matched for age and sex with 36 typically developing peers. The Fatigue Impact and Severity Self-Assessment (FISSA), the Patient-Reported Outcome Measurement Information System (PROMIS) fatigue profile, and the Sleep Disturbance Scale for Children (SDSC) were collected.

RESULTS

Higher fatigue was reported in participants with CP than in their typically developing peers based on the FISSA total score (mean paired difference=19.06; 99% confidence interval [CI], 6.06-32.1), the FISSA impact subscale (mean paired difference=11.19; 99% CI, 3.96-18.4), and the FISSA Management and Activity Modification subscale (mean paired difference=7.86; 99% CI, 1.1-14.6). There were no differences between groups in the PROMIS fatigue profile (mean paired difference=1.63; 99% CI, -1.57-4.83) or the SDSC total score (mean paired difference=2.71; 99% CI, -2.93-8.35).

CONCLUSION

Youth with CP experienced significantly more fatigue than their peers as assessed by a comprehensive measure that considered both general and diagnosis-specific concerns. Sleep did not differ between youth with CP and their typically developing peers. These findings underscore the need to consider the clinical management of fatigue across the lifespan of individuals with CP to prevent the associated deterioration of functional abilities.

Musculoskeletal Pain Outcomes Pre- and Post Intrathecal Baclofen Pump Implant in Children With Cerebral Palsy: A Prospective Cohort Study

Objective

To characterize musculoskeletal pain intensity, duration, frequency, and interference with activities of daily living in children with cerebral palsy (CP) before and after intrathecal baclofen pump placement.

Design

Prospective cohort study.

Setting

Children's tertiary hospital.

Participants

Participants were children with CP (N=32; 53% male; mean age, 9.9y; age range, 4-17y). The majority of participants had a CP diagnosis of quadriplegia (76%) and relied on wheeled mobility (91%).

Interventions

Assessments were completed pre- and post intrathecal baclofen pump implant.

Main Outcome Measures

Because of considerable patient heterogeneity, both pain measures (Brief Pain Inventory, Dalhousie Pain Interview) were completed by proxy (parent) report at the time of the procedure and approximately 6 months after intrathecal baclofen (ITB) pump placement.

Results

Prior to implant, 31% of participants were living with constant pain, which reduced to 6% post ITB implant (P<.001). Based on Wilcoxon signed rank tests, pain duration significantly decreased post ITB pump implant (P<.01).

Conclusions

This prospective analysis supports the anecdotal and retrospective evidence that musculoskeletal pain decreases in CP following ITB pump implant. The greatest effect appears to be on the duration of pain experience. Pain did not decrease for all individuals, and it would be worth further investigation to better understand the relation between patient characteristics and pain outcomes.

Screening Intrathecal Baclofen Pump Systems for Catheter Patency via Catheter Access Port Aspiration

OBJECTIVES

To screen all of our patients being treated with intrathecal baclofen (ITB) therapy for catheter patency.

METHOD

Catheter patency was examined by performing a catheter access port study in 91 pediatric and adult patients undergoing ITB therapy at our institution.

RESULTS

Despite no preoperative clinical suspicion of a problem with the ITB system in all but one case, 16.5% of the catheters in our patient population were not patent. After replacement, prerevision and stable postrevision dosage was examined to determine the impact system replacement had on the daily dosage. There was a significant 65% reduction in the daily ITB dosage from before catheter exploration (M = 823.8 mcg/day, SD = 390.51) to stable post replacement/revision dosage after catheter replacement or revision (M = 289.43 mcg/day, SD = 187.76), t₁₁ = 4.09, p = .002, 95% CI [246.80, 822.00].

CONCLUSIONS

These results suggest that catheters need to be routinely screened for patency. Routine maintenance and screening can minimize or more quickly detect nonpatent systems and ensure proper functioning of the ITB system.

Management of pain in children and adolescents with cerebral palsy: a systematic review

AIM

To determine the efficacy of interventions for the management of pain in children and adolescents with cerebral palsy (CP).

METHOD

Electronic databases were searched from the earliest date possible to April 2018 using a mixture of subject headings and free text. Inclusion criteria comprised of studies with (1) diagnosis of CP, (2) under the age of 18 years, (3) intervention for the management of pain, (4) outcome measure of pain, and (5) studies published in English-language peer-reviewed journals.

RESULTS

Fifty-seven studies met the eligibility criteria. Pain related to (n=number of studies): hypertonia (n=17), spastic hip disease (n=13), procedures for the management of CP (n=7), postoperative (n=18), and other (n=2). Most of the studies were of level III to level V evidence.

INTERPRETATION

There is level II evidence to support intrathecal baclofen therapy for pain secondary to hypertonia in spastic and spastic-dyskinetic CP, and non-pharmacological interventions for procedural pain and pharmacological interventions for postoperative pain. Most studies were restricted by retrospective design and limited use of validated outcome measures. Future research is needed to explore multidisciplinary interventions for chronic pain and pain secondary to dystonia. Clinicians and researchers would benefit from a standardized approach to pain assessment.

WHAT THIS PAPER ADDS

The strongest evidence exists for pharmacological treatments for postoperative pain in children and adolescents with cerebral palsy (CP). There is moderate evidence for the efficacy of intrathecal baclofen for pain related to hypertonia in predominately spastic CP. There is a lack of standardization in the assessment of pain. There is limited evidence for multimodal and non-pharmacological strategies in paediatric CP.

Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management

Intrathecal baclofen is an expanding accepted treatment for children with cerebral palsy and other causes of spasticity and dystonia. The aims of this review are therefore to (1) delineate the clinical benefits of intrathecal baclofen therapy in pediatric spasticity and dystonia and (2) increase awareness of the potential complications and emergency management measures of intrathecal baclofen therapy. A current literature review demonstrates the benefits and complications of this minimally invasive device. Practical guides for recognizing acute conditions and management recommendations are included. Intrathecal baclofen is increasingly being used to help individuals attain realistic functional goals. Therefore, families and health care professionals should be aware of potential complications, symptoms, and emergency management.

Intrathecal baclofen in dyskinetic cerebral palsy: effects on function and activity

AIM

To investigate the effect of intrathecal baclofen (ITB) on function and activity in dyskinetic cerebral palsy (CP).

METHOD

A retrospective cohort study of records from 25 children (15 males, 10 females; mean age 10y 11mo, SD 4y 9mo). Five were classified in Gross Motor Function Classification level IV and 20 in level V. Parents were interviewed about activities in daily life, sitting, communication, pain, sleep, and gross and fine motor function. Differences before and 1 year after ITB were graded as positive, no change, or negative. Assessments of dystonia (using the Barry-Albright Dystonia Scale) and muscle tone (Ashworth Scale) were made. Joint range of motion (ROM) was measured.

RESULTS

Both dystonia and increased muscle tone, present in all participants before ITB, decreased after (p<0.001). Passive ROM was restricted, with no difference after. Parents reported improvements in activities in daily life (p<0.001), sitting (p<0.001), communication (p<0.001), and fine motor function (p=0.013), but no change in gross motor function. Before ITB, pain and disturbed sleep were reported. There was a reduction in pain (p=0.002) and sleep improved (p=0.004) after ITB.

INTERPRETATION

After ITB in individuals with dyskinetic CP, improvements were found in sitting, communication, and fine motor skills. There was a reduction in dystonia and muscle tone, and pain and sleep improved.

WHAT THIS PAPER ADDS

Intrathecal baclofen can affect specific aspects of functioning in dyskinetic cerebral palsy. Sitting, communication, and fine motor function improved. Dystonia and spasticity were reduced. Pain was reduced and sleep improved.

Sleep Disorders in Childhood Neurological Diseases

Sleep problems are frequently addressed as a primary or secondary concern during the visit to the pediatric neurology clinic. Sleep disorders can mimic other neurologic diseases (e.g., epilepsy and movement disorders), and this adds challenges to the diagnostic process. Sleep disorders can significantly affect the quality of life and functionality of children in general and those with comorbid neurological diseases in particular. Understanding the pathophysiology of sleep disorders, recognizing the implications of sleep disorder in children with neurologic diseases and behavioral difficulties, and early intervention continue to evolve resulting in better neurocognitive outcomes.

Intrathecal baclofen therapy in paediatrics: a study protocol for an Australian multicentre, 10-year prospective audit

INTRODUCTION

Increasing clinical use of Intrathecal baclofen (ITB) in Australian tertiary paediatric hospitals, along with the need for standardised assessment and reporting of adverse events, saw the formation of the Australian Paediatric ITB Research Group (APIRG). APIRG developed a National ITB Audit tool designed to capture clinical outcomes and adverse events data for all Australian children and adolescents receiving ITB therapy.

METHODS AND ANALYSIS

The Australian ITB Audit is a 10 year, longitudinal, prospective, clinical audit collecting all adverse events and assessment data across body functions and structure, participation and activity level domains of the ICF. Data will be collected at baseline, 6 and 12 months with ongoing capture of all adverse event data. This is the first Australian study that aims to capture clinical and adverse event data from a complete population of children with neurological impairment receiving a specific intervention between 2011 and 2021. This multi-centre study will inform ITB clinical practice in children and adolescents, direct patient selection, record and aid decision making regarding adverse events and investigate the impact of ITB therapy on family and patient quality of life.

ETHICS AND DISSEMINATION

This project was approved by the individual Human Research Ethics committees at the six Australian tertiary hospitals involved in the study. Results will be published in various peer reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN 12610000323022; Pre-results.

Potential for Intrathecal Baclofen in Treatment of Essential Tremor

INTRODUCTION

Essential tremor (ET) is the most common movement disorder of adults, affecting an estimated 7 million Americans. Symptoms of ET range from slightly noticeable to debilitating, with 1 cohort study finding 15% of patients were forced into early retirement. Additionally, depression has also been correlated with the severity of disability of ET. Treatment options include propranolol and primidone. Current treatment options are not very effective, with more than half (56.3%) of patients discontinuing medications because of no changes in symptoms.

METHODS

Unfortunately, there is a relative void and controversy in the literature explaining ET pathophysiology; however, the gamma-aminobutyric acid (GABA) hypothesis is the strongest. We conducted a PubMed search on 30 September 2015 with no time constraints using the search terms "essential tremor" and "baclofen," which resulted in a total of 5 articles.

RESULTS

Neurohistopathologic studies have demonstrated decreased GABA-A and GABA-B receptors in the cerebellar cortex of ET patients. GABA, the major inhibitory neurotransmitter in the central nervous system, is proposed to have an inhibitory effect on pacemaker output activity of the cerebello-thalamo-cortical pathway, with lower receptors resulting in decreased inhibition of baseline tremors. Tariq et al showed delayed onset and intensity of tremor with oral administration of R-baclofen in a mouse model of ET.

CONCLUSION

With a better side-effect profile and success in a physiologically related condition, we propose more clinical trials and research be carried out on intrathecal baclofen as a potential treatment option, especially drug refractory ET, so as to increase the quality of life of this patient population.

Baclofen Pumps: Uses and Complications

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Intrathecal baclofen for treating spasticity in children with cerebral palsy

BACKGROUND

Cerebral palsy is a disorder of movement and posture arising from a non-progressive lesion in the developing brain. Spasticity, a disorder of increased muscle tone, is the most common motor difficulty and is associated with activity limitation to varying degrees in mobility and self care.Oral baclofen, a gamma-aminobutyric acid (GABA) agonist, has been used in oral form to treat spasticity for some time, but it has a variable effect on spasticity and the dose is limited by the unwanted effect of excessive sedation. Intrathecal baclofen produces higher local concentrations in cerebrospinal fluid at a fraction of the equivalent oral dose and avoids this excessive sedation.

OBJECTIVES

To determine whether intrathecal baclofen is an effective treatment for spasticity in children with cerebral palsy.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE and CINAHL databases, handsearched recent conference proceedings, and communicated with researchers in the field and pharmaceutical and drug delivery system companies.

SELECTION CRITERIA

We included studies which compared the effect of intrathecal baclofen treatment on spasticity, gross motor function or other areas of function with controls.

DATA COLLECTION AND ANALYSIS

Two authors selected studies, two authors extracted data and two authors assessed the methodological quality of included studies.

MAIN RESULTS

Six studies met the inclusion criteria. The data obtained were unsuitable for the conduct of a meta-analysis; we have completed a qualitative summary.All studies were found to have high or unclear risk of bias in some aspects of their methodology.Five of the six studies reported data collected in the randomised controlled phase of the study. A sixth study did not report sufficient results to determine the effect of intrathecal baclofen versus placebo. Of these five studies, four were conducted using lumbar puncture or other short-term means of delivering intrathecal baclofen. One study assessed the effectiveness of implantable intrathecal baclofen pumps over six months.The four short-term studies demonstrated that intrathecal baclofen therapy reduces spasticity in children with cerebral palsy. However, two of these studies utilised inappropriate techniques for statistical analysis of results. The single longer-term study demonstrated minimal reduction in spasticity with the use of intrathecal baclofen therapy.One of the short-term studies and the longer term study showed improvement in comfort and ease of care. The longer term study found a small improvement in gross motor function and also in some domains of health-related quality of life.Some caution is required in interpreting the findings of the all the studies in the review due to methodological issues. In particular, there was a high risk of bias in the methodology of the longer term study due to the lack of placebo use in the control group and the absence of blinding to the intervention after randomisation for both participants and investigators.

AUTHORS' CONCLUSIONS

There is some limited short-term evidence that intrathecal baclofen is an effective therapy for reducing spasticity in children with cerebral palsy. The effect of intrathecal baclofen on long-term spasticity outcomes is less certain.The validity of the evidence for the effectiveness of intrathecal baclofen in treating spasticity in children with cerebral palsy from the studies in the review is constrained by the small sample sizes of the studies and methodological issues in some studies.Spasticity is a impairment in the domain of body structure and function. Consideration must also be given to the broader context in determining whether intrathecal baclofen therapy is effective. The aim of therapy may be, for example, to improve gross motor function, to increase participation at a social role level, to improve comfort, to improve the ease of care by others or to improve the overall quality of life of the individual. Intrathecal baclofen may improve gross motor function in children with cerebral palsy, but more reliable evidence is needed to determine this.There is some evidence that intrathecal baclofen improves ease of care and the comfort and quality of life of the individuals receiving it, but again small sample sizes and methodological issues in the studies mean that these results should be interpreted with caution.Further evidence of the effectiveness of intrathecal baclofen for treating spasticity, increasing gross motor function and improving comfort, ease of care and quality of life is needed from other investigators in order to validate these results.The short duration of the controlled studies included in this review did not allow for the exploration of questions regarding whether the subsequent need for orthopaedic surgery in children receiving intrathecal baclofen therapy is altered, or the safety and the economic implications of intrathecal baclofen treatment when long-term therapy is administered via an implanted device. Controlled studies are not the most appropriate study design to address these questions, cohort studies may be more appropriate.

Intrathecal baclofen bolus dosing and catheter tip placement in pediatric tone management

Intrathecal baclofen (ITB), administered by an implanted pump, has emerged as an efficacious therapy for the treatment of hypertonicity in pediatrics. Although ITB has been used for more than 20 years clinically, much is still unknown about the most optimal dosing regimens and intrathecal catheter tip placement. Clinician experience, animal research, and advanced imaging is guiding the use of ITB. The rationale for high cervical catheter tip placement and pulsating flex dosing is described.

Understanding the reasons for delayed referral for intrathecal baclofen therapy in pediatric patients with severe spasticity

OBJECTIVE

Intrathecal baclofen therapy (ITB) has been used in the treatment of spasticity and dystonia. In our pediatric movement disorder clinic, we noted a delay in referral of patients for consideration of ITB. Often, only after years of failed medical therapy, a baclofen pump is considered. This study attempts to investigate the prevalence, length and causes of the delay.

METHODS

A retrospective, outcome analysis was performed. We conducted a survey of 30 pediatric patients who received baclofen pumps between the ages of 5 and 23. Patients were divided into two groups (before and after ITB approval by the US Food and Drug Administration in 1996) (FDA/Center for Drug Evaluation and Research, 2014; Ridley and Rawlins, J Neurosci Nurs 38:72-82, 2006; Medical Advisory Secretariat, Ont Health Technol Assess Ser 5:1-93, 2005). Information was collected regarding their onset of spasticity, attempted treatments, pump referral, satisfaction, and resulting change in the quality of life.

RESULTS

There was a delay in referral in most cases investigated. Average time to baclofen pump implantation, after initial onset of spasticity, was 5.14 years (group A) and 11.7 years (group B). Out of the subjects who reported diminished effects or no effect of pharmacological treatment, 93 % of these respondents reported that ITB had a dramatic long-lasting effect on their spasticity. Of 30 patients, 28 reported effectiveness of ITB, and 26 of 30 subjects reported an improved quality and ease of life.

CONCLUSION

Despite the limitations of this subjective retrospective analysis of outcomes and delay in referral, the opinions of the parents and caregivers should be considered. Earlier referral for ITB therapy may better treat severe spasticity in pediatric patients.

Pain in young people aged 13 to 17 years with cerebral palsy: cross-sectional, multicentre European study

OBJECTIVE

To determine the prevalence and associations of self- and parent-reported pain in young people with cerebral palsy (CP).

DESIGN AND SETTING

Cross-sectional questionnaire survey conducted at home visits in nine regions in seven European countries. Participants were 13 to 17-year-olds (n=667) drawn from population CP registers in eight regions and from multiple sources in one region. 429 could self-report; parent-reports were obtained for 657. Data were collected on: severity, frequency, site and circumstances of pain in previous week; severity of pain associated with therapy in previous year.

RESULTS

The estimated population prevalence of any pain in previous week was 74% (95% CI 69% to 79%) for self-reported pain and 77% (95% CI 73% to 81%) for parent-reported pain. 40% experienced leg pains, 34% reported headaches and 45% of those who received physiotherapy experienced pain during therapy. Girls reported more pain than boys (OR=2.1, 95% CI 1.5 to 3.0) and young people reported more pain if they had emotional difficulties (comparing highest and lowest quartiles: OR=3.1, 95% CI 1.7 to 5.6). Parents reported more pain in children with emotional difficulties (OR=4.2, 95% CI 2.7 to 6.6), or with more impaired walking ability.

CONCLUSIONS

Pain in young people with CP is highly prevalent. Because pain causes immediate distress and is associated with lower subjective well-being and reduced participation, clinicians should routinely assess pain. Clinical interventions to reduce pain should be implemented and evaluated. The efficacy of medical and therapeutic interventions causing pain should be re-examined to establish if their benefit justifies the pain and fear of pain that accompany them.

Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel

INTRODUCTION

The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences.

METHODS

The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain.

RESULTS

After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain.

CONCLUSIONS

The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.

Cervical catheter placement for intrathecal baclofen test dose: is it safe?

INTRODUCTION

Intrathecal baclofen testing is usually performed via a catheter inserted at the lumbar spine. However, in patients with scoliosis, the distorted anatomy and bone fusion from corrective spinal surgery obviates access at the lumbar spine.

PATIENTS AND METHODS

We report a method for inserting the intrathecal catheter via a posterior cervical approach and discuss our outcome. We describe our experience in 20 patients in whom intrathecal baclofen test catheter was inserted at the lower cervical spine. Data was collected prospectively.

DISCUSSION

The procedure was successful in all 20 patients. There were no complications as a result of surgery or from baclofen test dose administration via a cervical catheter. Of the 20 patients, 15 went on to have baclofen pump implantation via a cervical catheter. In one patient, subsequent pump implantation procedure was unsuccessful due to presence of extradural scar tissue. In the remaining four patients pump implantation was declined due impending corrective spinal surgery or social reasons.

CONCLUSION

Our experience shows that low cervical catheter insertion for administration of a test dose of intrathecal baclofen and feasible and safe to perform via the method described.

Intrathecal baclofen therapy in severe head injury, first time in Nepal, a technique suitable for underdeveloped countries

Intrathecal baclofen (ITB) has been found to be helpful not only for spasticity but also for unconsciousness in a vegetative patient. This is the first case of ITB in Nepal, and here we discuss the effectiveness of ITB for spasticity in a patient in vegetative state. We also discuss about a simple technique for ITB used in Nepal where baclofen pump is not available. Here, we present a case of a 40-year-old male patient who had severe head injury with diffuse axonal injury treated conservatively. He went on to a vegetative state and subsequently developed severe spasticity of all the limbs. ITB was started under the guidance of one of the authors , Prof. Taira. Baclofen was injected to the spinal intrathecal space through a catheter which is used for spinal anesthesia. Spasticity improved significantly and his higher mental function also showed signs of improvement. He finally became fully conscious and well oriented. ITB is very useful in cases of severe spasticity and vegetative condition, a state of unconsciousness lasting longer than a few weeks. Even with a simple technique in the absence of baclofen pump, ITB can be used with its optimum effect.

Sleep in children with cerebral palsy: a review

Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Does loss of spasticity matter? A 10-year follow-up after selective dorsal rhizotomy in cerebral palsy

AIM

The aim of this study was to evaluate the long-term effects of selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP).

METHOD

Nineteen children (four females, 15 males; mean age 4y 7mo, SD 1y 7mo) with bilateral spastic CP, were prospectively assessed at baseline and 18 months, 3 years, and 10 years after SDR. Assessments included the Modified Ashworth Scale for spasticity, the Gross Motor Function Measure 88 (GMFM-88) and the Wilson gait scale for ambulation, neurological investigations, and passive joint range of motion assessment. A 10-year retrospective chart review was added for orthopaedic surgery after SDR.

RESULTS

Baseline muscle tone at the hip, knee, and ankle level displayed a high degree of spasticity that normalized after SDR. After 10 years there was a slight recurrence of spasticity at the knee and ankle. Joint range of motion declined from a maximum at 3 years after SDR to the 10-year follow-up. Median ambulatory status was best 3 years after SDR and then declined. The GMFM-88 score increased from the median baseline value of 51 to 66 (p=0.002) and 76 (p<0.001) at the initial follow-ups. After 10 years there was a decline in gross motor function with a reduction in the GMFM-88 score to 62 (p=0.022). Within 10 years, 16 out of 19 patients had a mean of three orthopaedic surgeries (SD 2.8), soft tissue surgery being the most common.

INTERPRETATION

The spasticity-reducing effect of SDR, although pronounced, did not seem to improve long-term functioning or prevent contractures. This suggests that contracture development in CP is not mediated by spasticity alone.

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

OBJECTIVE

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

METHODS AND RESULTS

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

CONCLUSION

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