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Isler C, Cerci HM, Baghaki S, Aydin YS, Toklu S, Hanci MM. Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique". Oper Neurosurg (Hagerstown) 2024; 27:415-423. [PMID: 38531088 DOI: 10.1227/ons.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers. METHODS Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump. RESULTS Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications. CONCLUSION The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.
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Affiliation(s)
- Cihan Isler
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Huseyin Mert Cerci
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Semih Baghaki
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Koc University, Istanbul , Turkey
| | - Yekta Servet Aydin
- Department of Plastic and Reconstructive Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
| | - Süreyya Toklu
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
- Department of Neurosurgery, Erzurum City Hospital, Erzurum , Turkey
| | - Mehmet Murat Hanci
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul , Turkey
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Masrour M, Zare A, Presedo A, Nabian MH. Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis. BMC Neurol 2024; 24:143. [PMID: 38678195 PMCID: PMC11055284 DOI: 10.1186/s12883-024-03647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
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.
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Affiliation(s)
- Mahdi Masrour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Zare
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ana Presedo
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
| | - Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
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Qureshi AZ, Shacfe H, Ilyas A, Ayaz SB, Aljamaan KY, Moukais IS, Jameel M, Sami W, Ullah S. Complications of Intrathecal Baclofen Pump Therapy: An Institutional Experience from Saudi Arabia. Healthcare (Basel) 2023; 11:2820. [PMID: 37957965 PMCID: PMC10650704 DOI: 10.3390/healthcare11212820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
The intrathecal baclofen pump (ITB) is one of the advanced treatment options in the management of spasticity. This retrospective cohort study was conducted to identify the complications of ITB treatment at a tertiary care rehabilitation facility. Various demographic and technical factors were analyzed, which are less often reported in the literature. All patients with ITB who had their refill at the ITB clinic between November 2019 and March 2020 were included. Of 48 patients, 17 patients had 18 (37.5%) ITB-related complications. Catheter-related complications were most common, whereas loss of efficacy (16.7%) and baclofen withdrawal (14.5%) were the most common outcomes of complications. Only catheter occlusion had a significant relationship with the pattern of spastic quadriparesis (p = 0.001). Gender, rehabilitation diagnosis, patients' residence, and facility of ITB placement did not have significant association. Similarly, age, distance from hospital, disease onset, ITB therapy duration, and baclofen dose were not statistically significant in relation to ITB-related complications.
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Affiliation(s)
- Ahmad Zaheer Qureshi
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Hasan Shacfe
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Amara Ilyas
- Department of Physical Medicine and Rehabilitation, King Fahad Specialist Hospital, Damam 32553, Saudi Arabia
| | - Saeed Bin Ayaz
- Department of Rehabilitation Medicine, Sheikh Khalifa Bin Zayed Al Nahyan Hospital, Muzaffarabad 13100, Pakistan
| | - Khalid Yousef Aljamaan
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Medical Rehabilitation Department, King Fahad Hospital, Hofuf 36364, Saudi Arabia
| | - Imad Saeed Moukais
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Mohammed Jameel
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Department of Pain Medicine, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Waqas Sami
- Department of Pre-Clinical Affairs, College of Nursing, QU Health, Qatar University, Doha P.O. Box 2713, Qatar;
| | - Sami Ullah
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Department of Physical Medicine and Rehabilitation, Qatar Rehabilitation Institute, Doha P.O. Box 3050, Qatar
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Goal-Setting in Multiple Sclerosis-Related Spasticity Treated with Botulinum Toxin: The GASEPTOX Study. Toxins (Basel) 2022; 14:toxins14090582. [PMID: 36136520 PMCID: PMC9504895 DOI: 10.3390/toxins14090582] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/14/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Spasticity is one of the most disabling symptoms in multiple sclerosis (MS). Botulinum toxin injection (BTI) is a first-line treatment for focal spasticity. There is a lack of evidence of a functional improvement following BTI in MS-related spasticity. To describe goal-setting for BTI in MS, and evaluate the degree of attainment, using goal attainment scaling (GAS) 4-to-6 weeks after injection session, a one-year multi-center retrospective observational study assessing goal-setting and achievement during BTI session in spastic patients with MS was set up. Following the GAS method, patients and their physicians set up to three goals and scored their achievement 4 to 6 weeks thereafter. Commonly used goals from three centers were combined into a standardized list and 125 single BTI sessions were analyzed. The most frequent goals regarded lower limb (LL) impairments (equinovarus foot, toe claw) or locomotion (stability, walking distance, clinging) and accounted for 89.1%, versus 10.9% for upper limb (UL), mostly for mild-to-moderate MS. Overall, goals were frequently achieved (85.77%) mainly when related to gait and mobility rather than hygiene and ease of care. This study gives an overview on the most frequent, relevant, and achievable goals to be set in real-life practice of BTI for spasticity management in MS.
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Dallas J, Naftel RP, Shannon CN. Pediatric Intrathecal Baclofen Pumps: A Descriptive Analysis of Hospital Course and Associated Costs. Pediatr Neurosurg 2021; 56:334-344. [PMID: 33965955 DOI: 10.1159/000515988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study was to identify predictors of increased cost and postoperative length-of-stay (LOS) following intrathecal baclofen pump (ITBP) placement. METHODS Patients were derived from the 2009/2012 kids' inpatient database. Inclusion criteria were selected for patients with ICD-9 codes 343.X (infantile cerebral palsy), 86.06 (infusion pump insertion), 03.90 (spinal catheter insertion), and elective hospitalizations. Nonparametric univariate analysis and subsequent gamma log-link general linear modeling were used to identify significant predictors of cost/LOS (p < 0.05). RESULTS 529 unweighted patients (787 with survey weights applied) met criteria. Median LOS was 3.00 days, and median cost was USD 23,284. Following multivariate modeling, predictors of increased LOS (in days) included increased hospital ITBP volume (p = 0.027), small hospital size (+0.55, p = 0.004), device complications (+0.95, p < 0.001), procedural complications (+1.40, p < 0.001), additional procedures (+0.86, p < 0.001), electrolyte abnormalities (+3.74, p < 0.001), and neurological comorbidities (+1.60, p < 0.001). Factors associated with decreased LOS were paralysis (-0.53, p < 0.001), Northeastern hospital region (-0.55, p = 0.018), and investor-owned hospital status (-0.75, p = 0.001). Similarly, predictors of increased cost included race of Hispanic (+USD 1,156, p = 0.033) or "other" (+USD 2,158, p = 0.001), Northeast hospital region (+USD 4,120, p < 0.001), small (+USD 4,139, p < 0.001) or medium (+USD 3,368, p < 0.001) hospital sizes, additional procedures (+USD 1,649, p < 0.001), neurological comorbidities (+USD 3,222, p = 0.003), and increased LOS (p < 0.001). Factors associated with decreased cost included Western hospital region (-USD 1,594, p = 0.001), government hospitals (-USD 1,391, p = 0.019), and investor-owned hospitals (-USD 2,057, p = 0.021). CONCLUSION This study found multiple variables associated with increased cost/LOS following ITBP placement. Broadly, this analysis demonstrates national trends associated with increased cost following ITBP placement.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lewis RA, Hughes D, Sutton AJ, Wilkinson C. Quantitative Evidence Synthesis Methods for the Assessment of the Effectiveness of Treatment Sequences for Clinical and Economic Decision Making: A Review and Taxonomy of Simplifying Assumptions. PHARMACOECONOMICS 2021; 39:25-61. [PMID: 33242191 PMCID: PMC7790782 DOI: 10.1007/s40273-020-00980-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 05/29/2023]
Abstract
Sequential use of alternative treatments for chronic conditions represents a complex intervention pathway; previous treatment and patient characteristics affect both the choice and effectiveness of subsequent treatments. This paper critically explores the methods for quantitative evidence synthesis of the effectiveness of sequential treatment options within a health technology assessment (HTA) or similar process. It covers methods for developing summary estimates of clinical effectiveness or the clinical inputs for the cost-effectiveness assessment and can encompass any disease condition. A comprehensive review of current approaches is presented, which considers meta-analytic methods for assessing the clinical effectiveness of treatment sequences and decision-analytic modelling approaches used to evaluate the effectiveness of treatment sequences. Estimating the effectiveness of a sequence of treatments is not straightforward or trivial and is severely hampered by the limitations of the evidence base. Randomised controlled trials (RCTs) of sequences were often absent or very limited. In the absence of sufficient RCTs of whole sequences, there is no single best way to evaluate treatment sequences; however, some approaches could be re-used or adapted, sharing ideas across different disease conditions. Each has advantages and disadvantages, and is influenced by the evidence available, extent of treatment sequences (number of treatment lines or permutations), and complexity of the decision problem. Due to the scarcity of data, modelling studies applied simplifying assumptions to data on discrete treatments. A taxonomy for all possible assumptions was developed, providing a unique resource to aid the critique of existing decision-analytic models.
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Affiliation(s)
- Ruth A Lewis
- North Wales Centre for Primary Care Research, College of Health and Behavioural Sciences, Bangor University, CAMBRIAN 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
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Pennington M, Summers J, Coker B, Eddy S, Kartha MR, Edwards K, Freeman R, Goodden J, Powell H, Verity C, Peacock JL. Selective dorsal rhizotomy; evidence on cost-effectiveness from England. PLoS One 2020; 15:e0236783. [PMID: 32776949 PMCID: PMC7416930 DOI: 10.1371/journal.pone.0236783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 07/15/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives Selective dorsal rhizotomy (SDR) has gained interest as an intervention to reduce spasticity and pain, and improve quality of life and mobility in children with cerebral palsy mainly affecting the legs (diplegia). We evaluated the cost-effectiveness of SDR in England. Methods Cost-effectiveness was quantified with respect to Gross Motor Function Measure (GMFM-66) and the pain dimension of the Cerebral Palsy Quality of Life questionnaire for Children (CPQOL-Child). Data on outcomes following SDR over two years were drawn from a national evaluation in England which included 137 children, mean age 6.6 years at surgery. The incremental impact of SDR on GMFM-66 was determined through comparison with data from a historic Canadian cohort not undergoing SDR. Another single centre provided data on hospital care over ten years for 15 children undergoing SDR at a mean age of 7.0 years, and a comparable cohort managed without SDR. The incremental impact of SDR on pain was determined using a before and after comparison using data from the national evaluation. Missing data were imputed using multiple imputation. Incremental costs of SDR were determined as the difference in costs over 5 years for the patients undergoing SDR and those managed without SDR. Uncertainty was quantified using bootstrapping and reported as the cost-effectiveness acceptability curve. Results In the base case, the incremental cost-effectiveness ratios (ICERs) for SDR are £1,382 and £903 with respect to a unit improvement in GMFM-66 and the pain dimension of CPQOL-Child, respectively. Inclusion of data to 10 years indicates SDR is cheaper than management without SDR. Incremental costs and ICERs for SDR rose in sensitivity analysis applying an alternative regression model to cost data. Conclusions Data on outcomes from a large observational study of SDR and long-term cost data on children who did and did not receive SDR indicates SDR is cost-effective.
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Affiliation(s)
- Mark Pennington
- Kings Health Economics, Institute of Psychiatry Psychology and Neuroscience, Kings College London, London, United Kingdom
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- * E-mail:
| | - Jennifer Summers
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Bola Coker
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Saskia Eddy
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Muralikrishnan R. Kartha
- Kings Health Economics, Institute of Psychiatry Psychology and Neuroscience, Kings College London, London, United Kingdom
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | - Karen Edwards
- The Robert Jones & Agnes Hunt Hospital, Oswestry, United Kingdom
| | - Robert Freeman
- The Robert Jones & Agnes Hunt Hospital, Oswestry, United Kingdom
| | - John Goodden
- Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Helen Powell
- National Institute for Health and Care Excellence, Manchester, United Kingdom
| | | | - Janet L. Peacock
- King’s Technology Evaluation Centre, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
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Cai Y, Zhang CS, Liu S, Wen Z, Zhang AL, Guo X, Xue CC, Lu C. Add-On Effects of Chinese Herbal Medicine for Post-Stroke Spasticity: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:734. [PMID: 31316387 PMCID: PMC6610255 DOI: 10.3389/fphar.2019.00734] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/07/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Treatment for post-stroke spasticity (PSS) remains a major challenge in clinical practice. Chinese herbal medicine (CHM) is often administered to assist in routine care (RC) in the treatment of PSS, with increasing numbers of clinical research and preclinical studies suggesting that it has potential benefits. Therefore, we conducted a systematic review and meta-analysis to evaluate the add-on effects and safety of CHM for PSS. Methods: Five English and four Chinese databases were searched from their respective inception to 28 February 2018. We included randomized controlled trials that evaluated the add-on effects of CHM for PSS, based on changes in the scores of the (Modified) Ashworth Scale (AS or MAS), Fugl-Meyer Assessment of Sensorimotor Recovery (FMA), and Barthel Index (BI). Results: Thirty-five trials involving 2,457 patients were included. For upper-limb AS or MAS, the estimated add-on effects of CHM to RC were significantly better when using oral (SMD -1.79, 95% CI: -3.00 to -0.57) or topical CHM (SMD -1.06, 95% CI: -1.40 to -0.72). For lower-limb AS or MAS, significant add-on benefits to RC were also detected (SMD -1.01, 95% CI: -1.43 to -0.59 and SMD -1.16, 95% CI: -1.83 to -0.49) using oral and topical CHM, respectively. For FMA and BI, better results were detected when adding CHM to RC, except for the subgroup of oral CHM for upper-limb FMA. Ten of the 35 included studies reported safety information, with two of them mentioning two mild adverse events. Conclusions: Noting the quality concerns of the included trials, this review suggests that CHM appears to be a well-tolerated therapy for patients with PSS, and the potential add-on effects of CHM in reducing spasticity and improving the daily activities of patients with PSS require further rigorous assessment.
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Affiliation(s)
- Yiyi Cai
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Claire Shuiqing Zhang
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Shaonan Liu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Zehuai Wen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Anthony Lin Zhang
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Xinfeng Guo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Charlie Changli Xue
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Chuanjian Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
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Chan DY, Chan SS, Chan EK, Ng AY, Ying AC, Li AC, Chiu CC, Cheung N, Mak W, Sun DT, Zhu CX, Poon W. Blessing or burden? Long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. SURGICAL PRACTICE 2018; 22:105-110. [PMID: 30147745 PMCID: PMC6099513 DOI: 10.1111/1744-1633.12308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/10/2018] [Indexed: 12/01/2022]
Abstract
AIM The intrathecal baclofen pump is an effective treatment for spasticity. However, long-term results have reported patients' dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. PATIENTS AND METHODS We conducted a 16-year retrospective cohort study of patients with spasticity treated with an intrathecal baclofen pump at a university hospital from 2000 to 2016. The primary outcome was the rate of infection per puncture for baclofen pump refill. Secondary outcomes included the incidence of other complications, such as running out of baclofen causing symptomatic withdrawal symptoms, pump mechanical failure, pump battery end of life and the need for pump replacement. The clinical outcome was assessed by the Modified Ashworth Scale (mAS). RESULTS In total, 340 follow-up episodes with pump refill procedures were recorded. The average interval between each pump refill was 57.3 days (±15.4 days). The average duration of admission for each pump refill was 4 h and 49 min (from 2 h 23 min to 10 h). There were two events with established infection after puncture for the refill, giving rise to an infection rate per puncture of 0.6 percent (2/340).For the long-term clinical outcome, at an average follow-up period of 7.6 years, the postoperative mAS for spasticity was 2.0 ± 0.756, which was significantly better than the preoperative mAS at 3.75 ± 0.462 (P = 0.001). CONCLUSION Long-term aftercare with baclofen pump refill was safe, with an infection rate of 0.6 per cent per puncture for each refill. Long-term intrathecal baclofen pump was effective in the treatment of spasticity with persistent significant improvement in the spasticity scale.
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Affiliation(s)
- David Yuen‐Chung Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Steve Sik‐Kwan Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Emily Kit‐Ying Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Amelia Yikjin Ng
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Aaron Chee‐Lun Ying
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ara Cheuk‐Yin Li
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Candy Ching‐Pik Chiu
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ning Cheung
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Wai‐Kit Mak
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - David Tin‐Fung Sun
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Cannon Xian‐Lun Zhu
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Wai‐Sang Poon
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
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Shih STF, Tonmukayakul U, Imms C, Reddihough D, Graham HK, Cox L, Carter R. Economic evaluation and cost of interventions for cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:543-558. [PMID: 29319155 DOI: 10.1111/dmcn.13653] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/30/2022]
Abstract
AIM Economic appraisal can help guide policy-making for purchasing decisions, and treatment and management algorithms for health interventions. We conducted a systematic review of economic studies in cerebral palsy (CP) to inform future research. METHOD Economic studies published since 1970 were identified from seven databases. Two reviewers independently screened abstracts and extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Any discrepancies were resolved by discussion. RESULTS Of 980 identified references, 115 were included for full-text assessment. Thirteen articles met standard criteria for a full economic evaluation, two as partial economic evaluations, and 18 as cost studies. Six were full economic evaluations alongside clinical studies or randomized controlled trials, whereas seven involved modelling simulations. The economic case for administration of magnesium sulfate for imminent preterm birth is compelling, achieving both health gain and cost savings. Current literature suggests intrathecal baclofen therapy and botulinum toxin injection are cost-effective, but stronger evidence for long-term effects is needed. Lifestyle and web-based interventions are inexpensive, but broader measurement of outcomes is required. INTERPRETATION Prevention of CP would avoid significant economic burden. Some treatments and interventions have been shown to be cost-effective, although stronger evidence of clinical effectiveness is needed. What this paper adds Cost-effectiveness evidence shows prevention is the most significant strategy. Some treatments are cost-effective, but stronger evidence for long-term effectiveness is required. Comparison of treatment costs is challenging owing to variations in methodologies and varying clinical indications.
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Affiliation(s)
- Sophy T F Shih
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Utsana Tonmukayakul
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Christine Imms
- Centre for Disability and Development Research, Australian Catholic University, Fitzroy, Victoria, Australia
| | - Dinah Reddihough
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - H Kerr Graham
- Royal Children's Hospital, Parkville, Victoria, Australia
| | - Liz Cox
- Victorian Managed Insurance Authority, Melbourne, Victoria, Australia
| | - Rob Carter
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Lanig IS, New PW, Burns AS, Bilsky G, Benito-Penalva J, Bensmail D, Yochelson M. Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network, an International Initiative. Arch Phys Med Rehabil 2018; 99:1681-1687. [PMID: 29428347 DOI: 10.1016/j.apmr.2018.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 01/08/2018] [Accepted: 01/17/2018] [Indexed: 11/28/2022]
Abstract
The recognition, evaluation, and management of disabling spasticity in persons with spinal cord damage (SCD) is a challenge for health care professionals, institutions, health systems, and patients. To guide the assessment and management of disabling spasticity in individuals with SCD, the Ability Network, an international panel of clinical experts, developed a clinical care pathway. The aim of this pathway is to facilitate treatment decisions that take into account the effect of disabling spasticity on health status, individual preferences and treatment goals, tolerance for adverse events, and burden on caregivers. The pathway emphasizes a patient-centered, individualized approach and the need for interdisciplinary coordination of care, patient involvement in goal setting, and the use of assessment and outcome measures that lend themselves to practical application in the clinic. The clinical care pathway is intended for use by health care professionals who provide care for persons with SCD and disabling spasticity in various settings. Barriers to optimal spasticity management in these people are also discussed. There is an urgent need for the clinical community to clarify and overcome barriers (knowledge-based, organizational, health system) to optimizing the management of spasticity in people with SCD.
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Affiliation(s)
- Indira S Lanig
- Northern Colorado Rehabilitation Hospital, Johnstown, CO, Australia.
| | - Peter W New
- Spinal Rehabilitation Service, Caulfield Hospital, Alfred Health, Caulfield, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Epworth-Monash Rehabilitation Medicine Unit, Southern Medical School, Monash University, Clayton, Victoria, Australia; Rehabilitation and Aged Care Service, Kingston Centre, Monash Health, Cheltenham, VIC, Australia
| | - Anthony S Burns
- Division of Physiatry, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jesus Benito-Penalva
- Institut Guttmann, Neurorehabilitation Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Djamel Bensmail
- Department of Physical Medicine and Rehabilitation, R. Poincaré Hospital, AP-HP, University of Versailles Saint Quentin, Garches, France
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Mobolaji-Lawal M, Chaudhuri R, Marsh RH, Miller ES, Bhatia K. Generalized Itching and Lower-Extremity Spasticity in a Patient with Intrathecal Baclofen Pump. J Emerg Med 2018; 54:116-120. [PMID: 29079488 DOI: 10.1016/j.jemermed.2017.08.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/30/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | - Rittik Chaudhuri
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Regan H Marsh
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily S Miller
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kriti Bhatia
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Shirvalkar P, Poree LR, Krames ES. The Development of Algorithms for Pain Care Including Neuromodulation Therapies. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Cai Y, Zhang CS, Liu S, Wen Z, Zhang AL, Guo X, Lu C, Xue CC. Electroacupuncture for Poststroke Spasticity: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2017; 98:2578-2589.e4. [DOI: 10.1016/j.apmr.2017.03.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 12/01/2022]
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Vidal J, Slof J, Serrano D, Marqués T, Kumru H, Benito-Penalva J. Cost-effectiveness of Intrathecal Baclofen Therapy in severe refractory non-focal disabling spasticity: a Spanish hospital perspective. Expert Rev Pharmacoecon Outcomes Res 2016; 17:67-76. [PMID: 27142176 DOI: 10.1080/14737167.2016.1180247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Current knowledge about long-term economic consequences of Intrathecal Baclofen Therapy (ITB Therapy®) is incomplete. METHODS A markov model was developed to estimate long-term clinical and economic outcomes with ITB Therapy® and conventional medical management of severe refractory non-focal disabling spasticity. Clinical and cost inputs were obtained through a non-interventional, prospective, observational study in a Spanish neurorehabilitation hospital. RESULTS ITB Therapy® increased remaining lifetime costs by €35,605 and resulted in a gain of 1.06 quality-adjusted life-years (QALYs), thus showing an incremental cost-effectiveness ratio (ICER) of €33,619/QALY gained. In alternative scenarios, reflecting other clinical settings and management options, considerably lower ICER values were obtained. In particular, opportunities were identified to improve efficiency by setting clinically and economically sound targets for post-operation length of stay. CONCLUSION In the Spanish setting, ITB Therapy® resulted in an ICER close to €30,000/QALY gained; potential ways to reduce costs and further enhance efficiency can be identified.
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Affiliation(s)
- Joan Vidal
- a Fundació Institut Guttmann , Institut Universitari de Neurorehabilitació adscrit a la UAB , Badalona , Spain
| | - John Slof
- b Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - David Serrano
- c Autonomous Consultant , Barberá del Vallés , Spain
| | - Teresa Marqués
- a Fundació Institut Guttmann , Institut Universitari de Neurorehabilitació adscrit a la UAB , Badalona , Spain
| | - Hatice Kumru
- a Fundació Institut Guttmann , Institut Universitari de Neurorehabilitació adscrit a la UAB , Badalona , Spain
| | - Jesús Benito-Penalva
- a Fundació Institut Guttmann , Institut Universitari de Neurorehabilitació adscrit a la UAB , Badalona , Spain
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Navarrete-Opazo AA, Gonzalez W, Nahuelhual P. Effectiveness of Oral Baclofen in the Treatment of Spasticity in Children and Adolescents With Cerebral Palsy. Arch Phys Med Rehabil 2016; 97:604-618. [DOI: 10.1016/j.apmr.2015.08.417] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/21/2015] [Accepted: 08/12/2015] [Indexed: 11/24/2022]
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Wang ZM, Law JH, King NKK, Rajeswaran DK, Soh S, Rao JP, Ng WH, Chua KSG. Treatment of severe, disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore. Singapore Med J 2016; 57:8-12. [PMID: 26831310 DOI: 10.11622/smedj.2016005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months. METHODS A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications. RESULTS From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day. CONCLUSION Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.
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Affiliation(s)
- Zhe Min Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Hao Law
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Samantha Soh
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Jai Prashanth Rao
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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Abstract
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.
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Affiliation(s)
- Monika J Hasnat
- The Royal Children's HospitalVictorian Paediatric Rehabilitation ServiceFlemington RoadParkvilleMelbourneVictoriaAustralia3052
| | - James E Rice
- Women's and Children's Health NetworkPaediatric Rehabilitation Department72 King William RoadNorth AdelaideAdelaideSouth AustraliaAustralia5006
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Narendran RC, Duarte RV, Valyi A, Eldabe S. The need for and provision of intrathecal baclofen therapy for the management of spasticity in England: an assessment of the Hospital Episode Statistics database. BMJ Open 2015; 5:e007517. [PMID: 26129634 PMCID: PMC4486968 DOI: 10.1136/bmjopen-2014-007517] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate changes in the uptake of intrathecal baclofen (ITB) following commissioning of this therapy by the National Health Service (NHS) England in April 2013. The specific objectives of this study were: (i) to explore the gap between the need for and the actual provision of ITB services; and (ii) to compare England figures with other European countries with comparable data available. SETTING Data for ITB -related procedures were obtained from the Hospital Episode Statistics (HES) database from 2009/2010 to 2013/2014. PARTICIPANTS Patients receiving ITB for the management of spasticity. RESULTS The available data for implantation of ITB from 2009/2010 to 2013/2014 for the treatment of spasticity due to varied aetiologies show that there has not been an increase in uptake of this therapy. The estimated need for this treatment based on the incidence and prevalence of conditions susceptible to ITB therapy is between 4.6 and 5.7 per million population. Our analysis of the data available from the HES database showed that the actual number of implants is around 3.0 per million population. The same period 2009-2014 has seen an increase in the delivery of other neuromodulation techniques including spinal cord stimulation, deep brain stimulation and sacral nerve stimulation. CONCLUSIONS There is a considerable gap between the need for and provision of ITB figures nationally. Additionally, within the same area, we have observed important differences in the ITB service delivery between the various trusts. The reasons for this can be multifactorial, including individual experience and opinions, organisational structures, resource and financial limitations. Further research analysing the efficacy and cost-effectiveness of this treatment in the UK might inform the development of Technology Appraisal Guidance for ITB, potentially leading to an improvement in service provision.
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Affiliation(s)
- Rajesh C Narendran
- Department of Pain and Anaesthesia, The James Cook University Hospital, Middlesbrough, UK
| | - Rui V Duarte
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Sam Eldabe
- Department of Pain and Anaesthesia, The James Cook University Hospital, Middlesbrough, UK
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Pereira S, Richardson M, Mehta S, Teasell R, Miller T. Toning It Down: Selecting Outcome Measures for Spasticity Management Using a Modified Delphi Approach. Arch Phys Med Rehabil 2015; 96:518-523.e18. [DOI: 10.1016/j.apmr.2014.08.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 08/08/2014] [Accepted: 08/12/2014] [Indexed: 11/27/2022]
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Zettl UK, Henze T, Essner U, Flachenecker P. Burden of disease in multiple sclerosis patients with spasticity in Germany: mobility improvement study (Move I). THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2014; 15:953-966. [PMID: 24292503 DOI: 10.1007/s10198-013-0537-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 10/14/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To describe the current management patterns of multiple sclerosis (MS) patients with spasticity in Germany and the impact of MS spasticity on quality of life (QoL) and associated costs. METHODS Non-interventional, multicentre, cross-sectional and retrospective burden-of-disease study including 414 MS patients with spasticity (age from 25 to 80 years) from 42 clinical practices across Germany. All patients were diagnosed with MS-related spasticity based on neurological examination at least 12 months before inclusion in the study. Three different forms were completed on different aspects of the disease: the patient questionnaire, the chart documentation form and the physician questionnaire. RESULTS Mild, moderate and severe spasticity were found in 27.3, 44.0 and 28.7 % of patients, respectively. Associated symptoms and QoL scores were worse in patients with higher degrees of spasticity. In particular, higher mean scores for sleep impairment (mild vs. severe, 2.1 vs. 4.3), mean spasm count (3/day vs. 10.1/day), mean WEIMuS fatigue score (15.8 vs. 19.8), increased walking time (9.6 vs. 20.2 s) and lower mean QoL scores (MSQoL-54 physical subscale, 54.9 vs. 39.5; EQ-5D, 0.60 vs. 0.30) were reported in patients with severe spasticity in comparison to patients with mild spasticity. Patient management mainly comprised physiotherapy (mild vs. severe, 65.5 vs. 85.7 %) and medication (84.2 vs. 64.8 %) with baclofen. The average cost for patients with mild spasticity was €2,268/year, increasing to €8,688/patient/year for patients with severe spasticity. The health insurance costs showed the same trend. CONCLUSIONS MS patients with spasticity suffer a significant burden because of resulting disabilities and reduced QoL, especially in cases of severe spasticity. Moreover, spasticity causes high costs that increase with increasing severity.
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Affiliation(s)
- Uwe K Zettl
- Center of Neurology, University of Rostock, Gehlsheimer Str. 20, 18147, Rostock, Germany,
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Al-Khodairy AT, Wicky G, Nicolo D, Vuadens P. Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report. Brain Inj 2014; 29:527-32. [PMID: 25437354 DOI: 10.3109/02699052.2014.984759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Whenever oral treatment or botulinum toxin injections fail to control severe spasticity, a trial with intrathecal baclofen is recommended no earlier than 1 year after brain injury. When irreversible contractures are to be avoided, such a trial might be done earlier. Some have briefly reported cognitive modifications with this treatment. METHODS During the trial period, intrathecal baclofen is continuously infused by a portable external pump through an intrathecal catheter. The daily dose is adjusted according to the clinical response. If the expected response is obtained by reduction of spasticity, a programmable pump is then implanted. Throughout the procedure, close neuropsychological follow-up is pursued. RESULTS Two persons with extremely severe brain injury and spasticity received a programmable pump less than 10 months after trauma. Unexpectedly, one emerged from the minimally conscious state and the other from post-traumatic amnesia. CONCLUSIONS Intrathecal baclofen should be considered within the first year after brain injury whenever spasticity does not respond to medication. ITB lessens the degree of spasticity which in turn facilitates care and, thus, has the potential to limit contractures. After severe brain injury, this treatment might trigger recovery from altered states of consciousness, improve cognition and facilitate rehabilitation.
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Walter M, Altermatt S, Furrer C, Meyer-Heim A. Intrathecal baclofen therapy in children with severe spasticity: Outcome and complications. Dev Neurorehabil 2014; 17:368-74. [PMID: 23977869 DOI: 10.3109/17518423.2013.827256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate clinical efficacy and incidence of complications regarding intrathecal baclofen (ITB) therapy in children. METHODS Retrospective medical chart review of 15 paediatric patients with congenital brain injuries who underwent ITB implantation for treatment of severe spasticity between 2003 and 2009. RESULTS Compared to the preoperative state, ITB therapy significantly reduced spasticity of lower limbs with corresponding decrease of the modified Ashworth scale (p < 0.05), while baclofen dosage increased (p = 0.001). Cobb angle of patients with scoliosis prior to ITB therapy (n = 8) increased significantly (p < 0.05) during follow-up. Overall, 10 complications (nine device related and one accidental) were found in six patients (40%), mostly emerging within the first three years after implantation. CONCLUSION Intrathecal baclofen is an effective therapy option for paediatric patients to significantly reduce spasticity of lower limbs. The high incidence of complications implicates the need for a close monitoring of the patients especially in the early post-operative period.
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Affiliation(s)
- Matthias Walter
- Neuro-Urology, Spinal Cord Injury Centre & Research, University of Zurich, Balgrist University Hospital , Zurich , Switzerland
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Walter M, Altermatt S, Furrer C, Meyer-Heim A. Intrathecal baclofen therapy in children with acquired brain injuries after drowning: A case series. Brain Inj 2014; 29:98-103. [PMID: 25264924 DOI: 10.3109/02699052.2014.947630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Objective: To investigate clinical efficacy as well as the incidence and extent of complications regarding intrathecal baclofen (ITB) therapy in children. METHODS This is a retrospective medical chart review of three paediatric patients with acquired brain injuries (ABI) resulting from drowning who underwent ITB pump implantation for treatment of severe spasticity. RESULTS Compared to the pre-operative state, ITB therapy reduced spasticity with a corresponding decrease of modified Ashworth scale in upper (3.2 ± 1.4 to 1.3 ± 0.6) and lower extremities (3.5 ± 0.9 to 2.0 ± 1.0). Overall, six complications, five device-related and one accidental, were found in two out of three patients. CONCLUSION Intrathecal baclofen is an effective therapy option for paediatric patients with ABI after drowning to significantly reduce spasticity of upper and lower extremities. A word of caution must be addressed to the incidence and extent of complications related to ITB therapy.
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Affiliation(s)
- Matthias Walter
- Neuro-Urology, Spinal Cord Injury Centre & Research, University of Zurich, Balgrist University Hospital , Zurich , Switzerland
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Saulino M, Guillemette S, Leier J, Hinnenthal J. Medical cost impact of intrathecal baclofen therapy for severe spasticity. Neuromodulation 2014; 18:141-9; discussion 149. [PMID: 25145312 DOI: 10.1111/ner.12220] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the economic effects of intrathecal baclofen (ITB) for patients with severe spasticity based on costs of care before and after implantation of an intrathecal drug delivery system. MATERIALS AND METHODS An actuarial projection of post-implant experience in the absence of ITB intervention was used to simulate a continued conventional medical management protocol (ITB-free) by assuming a reasonable trend rate based on health-care industry standards. Cost projections were developed over a 30-year time horizon at various reimplantation rates. The model was informed by retrospective analysis of commercial administrative claims data from 409 pediatric and adult spasticity patients who received a pump implant (ITB-experienced) within a 3-year service period (January 2006 to January 2009). Common indications associated with pump implant included multiple sclerosis (N = 124), cerebral palsy (N = 131), and spinal cord injury (N = 40). RESULTS ITB was less costly than the conventional protocol over our baseline implantation cycle. Costs in the month of implant and in the year following were cumulatively $26,375 more than with the conventional protocol. However, ITB financial break-even occurs between the second and third years post-implant. The lifetime analysis indicates that savings for ITB are $8009 per patient per year compared with conventional therapy. Most of the savings are derived from reductions in inpatient admissions, physician office visits, and outpatient physiotherapy. CONCLUSIONS The results suggest that spasticity patients receiving ITB would expect to experience a reduction in cumulative future medical costs relative to anticipated costs in the absence of a pump implant. This finding complements the existing literature on the cost-effectiveness of ITB.
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Abstract
This review of the long-term management of spasticity addresses some of the clinical dilemmas in the management of patients with chronic disability. It is important for clinicians to have clear objectives in patient treatment and the available treatment strategies. The review reiterates the role of physical treatment in the management, and thereafter the maintenance of patients with spasticity. Spasticity is a physiological consequence of an injury to the nervous system. It is a complex problem which can cause profound disability, alone or in combination with the other features of an upper motor neuron syndrome, and can give rise to significant difficulties in the process of rehabilitation. This can be associated with profound restriction to activity and participation due to pain, weakness, and contractures. Optimum management is dependent on an understanding of its underlying physiology, an awareness of its natural history, an appreciation of the impact on the patient, and a comprehensive approach to minimizing that impact. The aim of this article is to highlight the importance, basic approach, and management options available to the general practitioner in such a complex condition.
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Affiliation(s)
- Anju Ghai
- Department of Anaesthesiology and Pain Medicine, Rohtak, Haryana, India
| | - Nidhi Garg
- Department of Anaesthesiology and Pain Medicine, Rohtak, Haryana, India
| | - Sarla Hooda
- Department of Anaesthesiology and Pain Medicine, Rohtak, Haryana, India
| | - Tushar Gupta
- Department of Anaesthesiology and Pain Medicine, Rohtak, Haryana, India
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Cardoso AL, Quintaneiro C, Seabra H, Teixeira C. Cardiac arrest due to baclofen withdrawal syndrome. BMJ Case Rep 2014; 2014:bcr-2014-204322. [PMID: 24827663 DOI: 10.1136/bcr-2014-204322] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 41-year-old man presented with postcervical traumatic complete quadriparesis under intrathecal baclofen therapy (ITB) for refractory spasticity. Less than 24 h after having his baclofen pump substituted, he develops hyperthermia, seizures, cognitive depression, acute hypoxaemic respiratory failure and cardiovascular instability leading to mechanical ventilation and vasopressor support. He was transferred to an intensive care unit with diagnosis of community-acquired pneumonia leading to septic shock. He evolved with progressive clinical worsening and multisystem organ failure and cardiac arrest in non-shockable rhythm (pulseless electrical activity)--4 min resuscitation with return of spontaneous circulation. Considering the possible diagnosis of baclofen withdrawal syndrome and, in suspicion of ITB delivery disruption, the catheter system was surgically explored and a leaking tubule attachment was found. Despite aggressive cardiovascular, respiratory and renal support therapy, clinical improvement occurred only after restoration of intrathecal drug delivery. He was discharged from the hospital after 56 days, having returned to baseline status.
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Affiliation(s)
- Ana Luísa Cardoso
- Department of Anesthesiology, Centro Hospitalar do Porto EPE, Porto, Portugal
| | - Claudio Quintaneiro
- Department of Internal Medicine of Hospital Distrital da Figueira da Foz EPE, Figueira da Foz, Portugal
| | - Helena Seabra
- Department of Anesthesiology, Centro Hospitalar do Porto EPE, Porto, Portugal
| | - Carla Teixeira
- Unidade de Cuidados Intensivos Polivalente do Centro Hospitalar do Porto EPE, Porto, Portugal
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Borrini L, Bensmail D, Thiebaut JB, Hugeron C, Rech C, Jourdan C. Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults. Arch Phys Med Rehabil 2014; 95:1032-8. [PMID: 24407102 DOI: 10.1016/j.apmr.2013.12.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/18/2013] [Accepted: 12/22/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors. DESIGN A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010. SETTING A neurologic rehabilitation department in a university hospital. PARTICIPANTS All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Frequency and type of AEs. RESULTS In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death. CONCLUSIONS The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.
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Affiliation(s)
- Léo Borrini
- Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France; Department of Physical Medicine and Rehabilitation, Percy Military Hospital, Clamart, France.
| | - Djamel Bensmail
- Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France; Versailles Saint Quentin en Yvelines University, Versailles, France
| | | | - Caroline Hugeron
- Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France
| | - Célia Rech
- Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France
| | - Claire Jourdan
- Department of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, Garches, France; Versailles Saint Quentin en Yvelines University, Versailles, France
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Ghai A, Sangwan SS, Hooda S, Garg N, Kundu ZS, Gupta T. Evaluation of interadductor approach in neurolytic blockade of obturator nerve in spastic patients. Saudi J Anaesth 2013; 7:420-6. [PMID: 24348294 PMCID: PMC3858693 DOI: 10.4103/1658-354x.121074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Spasticity is a syndrome associated with a persistent increase in involuntary reflex activity of a muscle in response to stretch. Adductor muscle spasticity is a common complication of spinal cord and brain injury. It needs to be treated if it interferes with activities of daily living and self-care. Obturator neurolytic blockade is one of the cost-effective therapeutic possibilities to treat spasticity of adductor group of muscles. In this study, we assessed the efficacy of interadductor approach in alleviating the spasticity. METHODS Obturator neurolysis using 8-10 ml 6% phenol was given with the guidance of a peripheral nerve stimulator in 20 spastic patients. Technical evaluation included number of attempted needle insertions, time to accurate location of the nerve, depth of needle insertion, and success rate. Pain, spasticity, hip abduction range of motion (ROM), number of spasms, gait, and hygiene were evaluated at 1(st) hour, 24(th) hour, end of the 1(st) week, and in the 1(st), 2(nd), and 3(rd) months following the intervention. RESULTS The success rate was 100% with mean time to accurate nerve location 4.9±2.06 min. Average depth of needle insertion was 2.91±0.32 cm. Compared with the scores measured immediately before the block, all studied parameters improved significantly. An increase in the Modified Ashworth Scale values was observed in the 2(nd) and 3(rd) months, but they did not reach their initial values. CONCLUSION The interadductor approach proved to be accurate and fast, with a high success rate. Phenol blockade is an efficient and cost-effective technique in patients with adductor spasticity. It led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene, with an efficacy lasting for about 3 months.
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Affiliation(s)
- Anju Ghai
- Department of Anaesthesiology and Pain Clinic, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Sukhbir Singh Sangwan
- Department of Orthopedics and Rehabilitation, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Sarla Hooda
- Department of Anaesthesiology and Pain Clinic, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Nidhi Garg
- Department of Anaesthesiology and Pain Clinic, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Zile S Kundu
- Department of Orthopedics and Rehabilitation, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Tushar Gupta
- Department of Anaesthesiology and Pain Clinic, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
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McGibbon CA, Sexton A, Jones M, O'Connell C. Elbow spasticity during passive stretch-reflex: clinical evaluation using a wearable sensor system. J Neuroeng Rehabil 2013; 10:61. [PMID: 23782931 PMCID: PMC3691589 DOI: 10.1186/1743-0003-10-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spasticity is a prevalent chronic condition among persons with upper motor neuron syndrome that significantly impacts function and can be costly to treat. Clinical assessment is most often performed with passive stretch-reflex tests and graded on a scale, such as the Modified Ashworth Scale (MAS). However, these scales are limited in sensitivity and are highly subjective. This paper shows that a simple wearable sensor system (angle sensor and 2-channel EMG) worn during a stretch-reflex assessment can be used to more objectively quantify spasticity in a clinical setting. METHODS A wearable sensor system consisting of a fibre-optic goniometer and 2-channel electromyography (EMG) was used to capture data during administration of the passive stretch-reflex test for elbow flexor and extensor spasticity. A kinematic model of unrestricted passive joint motion was used to extract metrics from the kinematic and EMG data to represent the intensity of the involuntary reflex. Relationships between the biometric results and clinical measures (MAS, isometric muscle strength and passive range of motion) were explored. RESULTS Preliminary results based on nine patients with varying degrees of flexor and extensor spasticity showed that kinematic and EMG derived metrics were strongly correlated with one another, were correlated positively (and significantly) with clinical MAS, and negatively correlated (though mostly non-significant) with isometric muscle strength. CONCLUSIONS We conclude that a wearable sensor system used in conjunction with a simple kinematic model can capture clinically relevant features of elbow spasticity during stretch-reflex testing in a clinical environment.
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Affiliation(s)
- Chris A McGibbon
- Institute of Biomedical Engineering, University of New Brunswick, 25 Dineen Dr., Fredericton, NB, Canada.
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Thrasher TA, Fisher S. Societal Costs of Intrathecal Drug Delivery Systems-An Administrative Analysis Based on Patient Claims. Neuromodulation 2013; 16:261-5; discussion 265. [DOI: 10.1111/ner.12029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 11/20/2012] [Accepted: 12/31/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Timothy Adam Thrasher
- Center for Neuromotor and Biomechanics Research; University of Houston; Houston; TX; USA
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33
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Tyurenkov IN, Borodkina LE, Bagmetova VV. Functional Aspects of Neuroprotective Effects of New Salts and Compositions of Baclofen in the Convulsive Syndrome Caused by Electroshock. Bull Exp Biol Med 2012; 153:710-3. [DOI: 10.1007/s10517-012-1806-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dobkin BH, Dorsch A. The promise of mHealth: daily activity monitoring and outcome assessments by wearable sensors. Neurorehabil Neural Repair 2012; 25:788-98. [PMID: 21989632 DOI: 10.1177/1545968311425908] [Citation(s) in RCA: 222] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mobile health tools that enable clinicians and researchers to monitor the type, quantity, and quality of everyday activities of patients and trial participants have long been needed to improve daily care, design more clinically meaningful randomized trials of interventions, and establish cost-effective, evidence-based practices. Inexpensive, unobtrusive wireless sensors, including accelerometers, gyroscopes, and pressure-sensitive textiles, combined with Internet-based communications and machine-learning algorithms trained to recognize upper- and lower-extremity movements, have begun to fulfill this need. Continuous data from ankle triaxial accelerometers, for example, can be transmitted from the home and community via WiFi or a smartphone to a remote data analysis server. Reports can include the walking speed and duration of every bout of ambulation, spatiotemporal symmetries between the legs, and the type, duration, and energy used during exercise. For daily care, this readily accessible flow of real-world information allows clinicians to monitor the amount and quality of exercise for risk factor management and compliance in the practice of skills. Feedback may motivate better self-management as well as serve home-based rehabilitation efforts. Monitoring patients with chronic diseases and after hospitalization or the start of new medications for a decline in daily activity may help detect medical complications before rehospitalization becomes necessary. For clinical trials, repeated laboratory-quality assessments of key activities in the community, rather than by clinic testing, self-report, and ordinal scales, may reduce the cost and burden of travel, improve recruitment and retention, and capture more reliable, valid, and responsive ratio-scaled outcome measures that are not mere surrogates for changes in daily impairment, disability, and functioning.
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Affiliation(s)
- Bruce H Dobkin
- Department of Neurology, Geffen UCLA School of Medicine, Los Angeles, CA, USA.
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Slof J, Gras A. Sativex® in multiple sclerosis spasticity: a cost-effectiveness model. Expert Rev Pharmacoecon Outcomes Res 2012; 12:439-41. [PMID: 22681512 DOI: 10.1586/erp.12.40] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic, progressive disease that carries a high socioeconomic burden. Spasticity (rigidity and spasms) is common in MS and a key contributor to MS-related disability. OBJECTIVES This study evaluated the cost-effectiveness of Sativex®, a 9-d-tetrahydrocannabinol/cannabidiol-based oromucosal spray that acts as an endocannabinoid system modulator. Sativex was recently approved for the management of resistant MS spasticity as add-on medication. METHODS A Markov model-based analysis was performed over a 5-year horizon from a German and Spanish healthcare payer perspective. The incremental cost of Sativex was low compared with current spasticity treatments, and provided a quality-adjusted life-year gain over the current standard of care. RESULTS The base-case incremental cost-effectiveness ratio for Sativex was estimated at €11,214/quality-adjusted life-year in Germany, while the drug was the dominant option in Spain, providing savings of €3496/patient over a 5-year period (year of costing: 2010). This was seen because the lower severity of spasticity in patients who had improved led to reduced resource consumption (e.g., physiotherapy and medications). CONCLUSION Despite having a relatively high acquisition cost, Sativex was shown to be a cost-effective treatment option for patients with MS-related spasticity.
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Affiliation(s)
- John Slof
- Universitat Autònoma de Barcelona, Campus de la UAB, Bellaterra, Spain
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36
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Marko NF, Weil RJ. An Introduction to Comparative Effectiveness Research. Neurosurgery 2012; 70:425-34; discussion 434. [DOI: 10.1227/neu.0b013e3182320a9e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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HATTORI N, HIRAYAMA T, KATAYAMA Y. Cost-Effectiveness Analysis of Intrathecal Baclofen Therapy in Japan. Neurol Med Chir (Tokyo) 2012; 52:482-7. [DOI: 10.2176/nmc.52.482] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Naoyuki HATTORI
- Department of Neurological Surgery, Nihon University School of Medicine
| | - Teruyasu HIRAYAMA
- Department of Neurological Surgery, Nihon University School of Medicine
| | - Yoichi KATAYAMA
- Department of Neurological Surgery, Nihon University School of Medicine
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Erwin A, Gudesblatt M, Bethoux F, Bennett SE, Koelbel S, Plunkett R, Sadiq S, Stevenson VL, Thomas AM, Tornatore C, Zaffaroni M, Hughes M. Intrathecal baclofen in multiple sclerosis: Too little, too late? Mult Scler 2011; 17:623-9. [DOI: 10.1177/1352458510395056] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The majority of patients with multiple sclerosis (MS) have symptoms of spasticity that increasingly impair function as the disease progresses. With appropriate treatment, however, quality of life can be improved. Oral antispasticity medications are useful in managing mild spasticity but are frequently ineffective in controlling moderate to severe spasticity, because patients often cannot tolerate the adverse effects of increasing doses. Intrathecal baclofen (ITB) therapy can be an effective alternative to oral medications in patients who have a suboptimal response to oral medications or who cannot tolerate dose escalation or multidrug oral regimens. ITB therapy may be underutilized in the MS population because clinicians (a) are more focused on disease-modifying therapies rather than symptom control, (b) underestimate the impact of spasticity on quality of life, and (c) have concerns about the cost and safety of ITB therapy. Delivery of ITB therapy requires expertly trained staff and proper facilities for pump management. This article summarizes the findings and recommendations of an expert panel on the use of ITB therapy in the MS population and the role of the physician and comprehensive care team in patient selection, screening, and management.
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Affiliation(s)
- April Erwin
- Georgetown University Hospital, Washington, DC, USA
| | | | - Francois Bethoux
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Stephen Koelbel
- Braintree Rehabilitation Hospital, Spasticity Management Program, Braintree, MA, USA
| | | | - Saud Sadiq
- Multiple Sclerosis Research Center of New York, New York, NY, USA
| | | | | | | | - Mauro Zaffaroni
- Centro Studi Sclerosi Multipla, S.Antonio Abate Hospital, Gallarate, Italy
| | - Mary Hughes
- Georgetown University Hospital, Washington, DC, USA
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Stetkarova I, Yablon SA, Kofler M, Stokic DS. Review: Procedure- and Device-Related Complications of Intrathecal Baclofen Administration for Management of Adult Muscle Hypertonia: A Review. Neurorehabil Neural Repair 2010; 24:609-19. [DOI: 10.1177/1545968310363585] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Intrathecal baclofen (ITB) effectively reduces muscle hypertonia; however, associated complications influence its utility and acceptance. Objective. To systematically review the literature on procedure- and device-related complications associated with ITB infusion therapy for adult muscle hypertonia of spinal or cerebral origin. Methods. The authors searched the PubMed database for full-length articles published in English that reported ITB-associated complications in adults. Of 147 articles retrieved, 32 full-length manuscripts and 10 case reports were reviewed in detail. Results. Overall, 558 complications were reported after 1362 pump implants (0.41 per implant). Methods for characterizing complications varied greatly between studies, as did complication rates, ranging from 0 to 2.24 per implant. Of the 558 complications, 148 (27%) were related to surgical procedures, 39 (7%) to pump problems, and 369 (66%) to catheter malfunctions. The overall complication rate was higher for studies that followed patients for more than 18 months on average (mean 0.56/implant) versus studies with shorter follow-up (0.23/implant, P < .05). Although correlation between the number of implants and the number of complications was significant ( r = .58), the goodness of linear fit was poor because of clusters with varied complication rates. Conclusions. Catheter problems are relatively common and more frequent than pump or surgical procedure complications after ITB pump implantation. Higher complication rates should be expected in centers that follow patients for a longer period of time. Standardized data collection and complication-reporting procedures along with appropriate training should be implemented in centers offering ITB treatment for management of muscle hypertonia.
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Affiliation(s)
- Ivana Stetkarova
- Na Homolce Hospital, Prague, Czech Republic, Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, Mississippi, USA
| | - Stuart A. Yablon
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, Mississippi, USA, Baylor Institute for Rehabilitation, Dallas, Texas, USA
| | | | - Dobrivoje S. Stokic
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, Mississippi, USA,
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