Examining the effectiveness of intrathecal baclofen on spasticity in individuals with chronic spinal cord injury: a systematic review

Combination of induced pluripotent stem cell-derived motor neuron progenitor cells with irradiated brain-derived neurotrophic factor over-expressing engineered mesenchymal stem cells enhanced restoration of axonal regeneration in a chronic spinal cord injury rat model

BACKGROUND

Spinal cord injury (SCI) is a disease that causes permanent impairment of motor, sensory, and autonomic nervous system functions. Stem cell transplantation for neuron regeneration is a promising strategic treatment for SCI. However, selecting stem cell sources and cell transplantation based on experimental evidence is required. Therefore, this study aimed to investigate the efficacy of combination cell transplantation using the brain-derived neurotrophic factor (BDNF) over-expressing engineered mesenchymal stem cell (BDNF-eMSC) and induced pluripotent stem cell-derived motor neuron progenitor cell (iMNP) in a chronic SCI rat model.

METHOD

A contusive chronic SCI was induced in Sprague-Dawley rats. At 6 weeks post-injury, BDNF-eMSC and iMNP were transplanted into the lesion site via the intralesional route. At 12 weeks post-injury, differentiation and growth factors were evaluated through immunofluorescence staining and western blot analysis. Motor neuron differentiation and neurite outgrowth were evaluated by co-culturing BDNF-eMSC and iMNP in vitro in 2-dimensional and 3-dimensional.

RESULTS

Combination cell transplantation in the chronic SCI model improved behavioral recovery more than single-cell transplantation. Additionally, combination cell transplantation enhanced mature motor neuron differentiation and axonal regeneration at the injured spinal cord. Both BDNF-eMSC and iMNP played a critical role in neurite outgrowth and motor neuron maturation via BDNF expression.

CONCLUSIONS

Our results suggest that the combined transplantation of BDNF- eMSC and iMNP in chronic SCI results in a significant clinical recovery. The transplanted iMNP cells predominantly differentiated into mature motor neurons. Additionally, BDNF-eMSC exerts a paracrine effect on neuron regeneration through BDNF expression in the injured spinal cord.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

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

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

Outcomes of Pressure Sore Surgery in Patients with Spinal Cord Injury and Spasticity

Background

Spasticity is a serious complication of spinal cord injury/disease (SCI/D) that affects 60%-80% of patients with this condition. The presence of spasticity can have a significant impact on the outcomes of reconstructive surgical interventions, such as those on pressure sores (PSs). Moreover, in the conservative treatment of PSs, spasticity may prevent maintaining adequate postures to avoid skin friction or traction. The aim of this study is to describe the PS reconstruction outcomes in a cohort of patients with SCI/D affected by spasticity.

Methods

In this retrospective study of patients with SCI/D consecutively admitted to Montecatone Rehabilitation Institute between October 2013 and March 2022, 54 PSs were treated in 46 people with spasticity.

Results

Postsurgery complications occurred in 26 of 54 treated PS, of which seven were major. Eleven patients experienced more than one complication. The overall incidence of postsurgical complications was 48.1%, and the incidence of major complications was 13%. Median length of hospital stay was 3.8 versus 1.8 months. Compared with other reports in the literature of PS reconstruction in patients with SCI/D, we found higher rates of overall, minor, and major complications.

Conclusions

Spasticity proved to be an important condition to consider, and its treatment requires specialized physicians. The collaboration between plastic surgeons and spasticity specialists is crucial to define the best treatment to reduce postoperative complications.

Intrathecal baclofen for the management of hereditary spastic paraparesis: a systematic review

This systematic review aims to evaluate the use of intrathecal baclofen (ITB) for hereditary spastic paraparesis (HSP) treatment. An extensive search in two electronical databases was performed. We identified articles published between 1990 and 2022 (PubMed, Scopus), and applied the following inclusion criteria: diagnosis of HSP at the time of the intervention, either familial or sporadic; report on the effect of ITB in patients with HSP; test trial via either bolus injections or continuous infusion tests; and ITB pump implantation. A data extraction sheet based on the Cochrane Consumers and Communication Review Group's data extraction template was created and adapted to collect relevant data. A qualitative analysis was performed to present the results in narrative summary fashion. A total of 6 studies met our inclusion criteria. 51 patients with HSP had a pre-implantation ITB trial. The time since the diagnosis until the pump implantation ranged from 5 to 30 years. The initial bolus ranged from 20 to 50 μg and the mean doses used at steady state ranged from 65 to 705 μg. An improvement in spasticity was observed on the modified Ashworth Scale in patients treated with ITB. Although all studies reported a subjective gait improvement, not all found an objective improvement in gait. The most common side effect reported was catheter-related problems. The findings of this review support the use of ITB as an effective and a viable option for the treatment of spasticity in HSP refractory to conservative therapies.

Characteristics of Changes in Intrathecal Baclofen Dosage over Time due to Causative Disease

Intrathecal baclofen (ITB) therapy effectively treats spasticity caused by brain or spinal cord lesions. However, only a few studies compare the course of treatment for different diseases. We investigated the change in daily dose of baclofen per year and its associated adverse events in patients presenting with the three most common etiologies at our institute: hereditary spastic paraplegia, cerebral palsy, and spinal cord injury. The ITB pumps were implanted from July 2007 to August 2019, with a mean follow-up period of 70 months. In patients with hereditary spastic paraplegia, baclofen dosage was reduced after eight years following ITB introduction, and the treatment was terminated in one patient owing to disease progression. In patients with cerebral palsy, the dosage increased gradually, and became constant in the 11th year. Patients with spinal cord injury gradually increased their baclofen dosage throughout the entire observation period. Severity and adverse event rates were higher in patients with cerebral palsy than in others. The degree and progression of spasticity varied depending on the causative disease. Understanding the characteristics and natural history of each disease is important when continuing ITB treatment.

[Surgical procedures for treatment of spasticity]

BACKGROUND

The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life.

OBJECTIVE

A review of surgical treatment options for spasticity.

MATERIAL AND METHODS

A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity.

RESULTS

Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections.

CONCLUSION

Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.

Regulation of the JAK/STAT signaling pathway in spinal cord injury: an updated review

Cytokines are involved in neural homeostasis and pathological processes associated with neuroinflammation after spinal cord injury (SCI). The biological effect of cytokines, including those associated with acute or chronic SCI pathologies, are the result of receptor-mediated signaling through the Janus kinases (JAKs) as well as the signal transducers and activators of transcription (STAT) DNA-binding protein families. Although therapies targeting at cytokines have led to significant changes in the treatment of SCI, they present difficulties in various aspects for the direct use by patients themselves. Several small-molecule inhibitors of JAKs, which may affect multiple pro-inflammatory cytokine-dependent pathways, as well as STATs, are in clinical development for the treatment of SCI. This review describes the current understanding of the JAK-STAT signaling in neuroendocrine homeostasis and diseases, together with the rationale for targeting at this pathway for the treatment of SCI.

A Scoping Review of Epidural Spinal Cord Stimulation for Improving Motor and Voiding Function Following Spinal Cord Injury

Objectives

To identify and synthesize the existing evidence on the effectiveness and safety of epidural spinal cord stimulation (SCS) for improving motor and voiding function and reducing spasticity following spinal cord injury (SCI).

Methods

This scoping review was performed according to the framework of Arksey and O'Malley. Comprehensive serial searches in multiple databases (MEDLINE, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, LILACS, PubMed, Web of Science, and Scopus) were performed to identify relevant publications that focused on epidural SCS for improving motor function, including spasticity, and voiding deficits in individuals with SCI.

Results

Data from 13 case series including 88 individuals with complete or incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] grade A to D) were included. In 12 studies of individuals with SCI, the majority (83 out of 88) demonstrated a variable degree of improvement in volitional motor function with epidural SCS. Two studies, incorporating 27 participants, demonstrated a significant reduction in spasticity with SCS. Two small studies consisting of five and two participants, respectively, demonstrated improved supraspinal control of volitional micturition with SCS.

Conclusion

Epidural SCS can enhance central pattern generator activity and lower motor neuron excitability in individuals with SCI. The observed effects of epidural SCS following SCI suggest that the preservation of supraspinal transmission is sufficient for the recovery of volitional motor and voiding function, even in patients with complete SCI. Further research is warranted to evaluate and optimize the parameters for epidural SCS and their impact on individuals with differing degrees of severity of SCI.

Neuromodulation and quality of life for patient with spasticity after spinal cord injury

RATIONALE

Spasticity develops in 80% of spinal cord injury cases and negatively affects the patents' quality of life. The most common method of surgical treatment for severe spasticity is a long-term intrathecal baclofen therapy (ITB). Long-term spinal cord stimulation is another possible treatment technique. This paper aims to evaluate the changes in quality of life for patients with spasticity who have been treated with neuromodulation (SCS or ITB) in 12 months after the surgery, as well to compare the changes in quality of life for patients who have been treated with spinal cord stimulation and those who received long-term intrathecal baclofen therapy.

MATERIALS AND METHODS

The influence of spasticity, experienced by the patients with a spinal cord injury, on their quality of life was analyzed before the surgery and 12 months after it. The severity of the spinal cord damage was determined with the scale of the American Spinal Injury Association (ASIA); spasticity was evaluated with the modified Ashworth scale, Penn Spasm Frequency Scale; pain levels were determined with visual analogue scale (VAS), anxiety and depression levels - with HADS. Functional activity of the patients was evaluated with the help of the Functional Independence Measure (FIM).

RESULTS

The treatment results for 33 patients (25 men and 8 women), aged from 18 to 62, are presented. After the trial stimulation, the patients were randomly assigned to either SCS or ITB group (18 and 15 people respectively). The decrease of spasticity in both experimental groups caused lower levels of pain, less functional dependency on other people, lower stress and depression rates and, as a consequence, better quality of life and social adaptation. The obtained results for SCS and ITB groups are statistically similar.

Effects of percutaneously-implanted epidural stimulation on cardiovascular autonomic function and spasticity after complete spinal cord injury: A case report

Importance

There is a revived interest to explore spinal cord epidural stimulation (SCES) to improve physical function after spinal cord injury (SCI). This case report highlights the potential of eliciting multiple functional improvements with a single SCES configuration, a strategy which could improve clinical translation.

Objective

To determine whether SCES intended to facilitate walking also acutely yields benefits in cardiovascular autonomic regulation and spasticity.

Design

Case report from data collected at two timepoints 15 weeks apart from March to June 2022 as part of a larger clinical trial.

Setting

Research lab at Hunter Holmes McGuire VA Medical Center.

Participant

27-year-old male, 7 years post a C8 motor complete spinal cord injury.

Intervention

A SCES configuration intended to enhance exoskeleton-assisted walking training applied for autonomic and spasticity management.

Main outcomes and measures

The primary outcome was cardiovascular autonomic response to a 45-degree head-up-tilt test. Systolic blood pressure (SBP), heart rate (HR), and absolute power of the low-frequency (LF) and high-frequency (HF) components of a heart-rate variability analysis were collected in supine and tilt with and without the presence of SCES. Right knee flexor and knee extensor spasticity was assessed via isokinetic dynamometry with and without SCES.

Results

At both assessments with SCES off, transitioning from supine to tilt decreased SBP (assessment one: 101.8 to 70 mmHg; assessment two: 98.9 to 66.4 mmHg). At assessment one, SCES on in supine (3 mA) increased SBP (average 117 mmHg); in tilt, 5 mA stabilized SBP near baseline values (average 111.5 mmHg). At assessment two, SCES on in supine (3 mA) increased SBP (average 140 mmHg in minute one); decreasing amplitude to 2 mA decreased SBP (average 119 mmHg in minute five). In tilt, 3 mA stabilized SBP near baseline values (average 93.2 mmHg). Torque-time integrals at the right knee were reduced at all angular velocities for knee flexors (range: -1.9 to -7.8%) and knee extensors (range: -1 to -11.4%).

Conclusions and relevance

These results demonstrate that SCES intended to facilitate walking may also enhance cardiovascular autonomic control and attenuate spasticity. Using one configuration to enhance multiple functions after SCI may accelerate clinical translation.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/, identifier NCT04782947.

[Methods and results of neurosurgical treatment of cerebral palsy]

Treatment of spastic syndrome and muscular dystonia in patients with cerebral palsy is a complex clinical problem. Effectiveness of conservative treatment is not high enough. Modern neurosurgical techniques for spastic syndrome and dystonia are divided into destructive interventions and surgical neuromodulation. Their effectiveness is different and depends on the form of disease, severity of motor disorders and age of patients.

OBJECTIVE

To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.

MATERIAL AND METHODS

We To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.analyzed literature data in the PubMed database using the keywords «cerebral palsy», «spasticity», «dystonia», «selective dorsal rhizotomy», «selective neurotomy», «intrathecal baclofen therapy», «spinal cord stimulation», «deep brain stimulation».

RESULTS

Effectiveness of neurosurgery was higher for spastic forms of cerebral palsy compared to secondary muscular dystonia. Destructive procedures were the most effective among neurosurgical operations for spastic forms. Effectiveness of chronic intrathecal baclofen therapy decreases in follow-up due to secondary drug resistance. Destructive stereotaxic interventions and deep brain stimulation are used for secondary muscular dystonia. Effectiveness of these procedures is low.

CONCLUSION

Neurosurgical methods can partially reduce severity of motor disorders and expand the possibilities of rehabilitation in patients with cerebral palsy.

Modulation of Motor Cortex Activity After Intrathecal Baclofen Delivery in Chronic Thoracic Spinal Cord Injury

Objectives

Intrathecal baclofen (ITB) is commonly used for reduction of spasticity in chronic spinal cord injury (SCI). Its clinical effect is well-known; however, exact mechanisms of long-term effect of continuous ITB administration (cITBa) on modulation of cortical processes have not been elucidated. The aim of this study was to evaluate changes in motor cortex activation for healthy upper limbs in comparison to impaired lower limbs by functional magnetic resonance imaging (fMRI).

Methods

Ten subjects (eight males, 20–69 years) with thoracic SCI presenting no voluntary movements of lower limbs (except one) were enrolled in the fMRI study. fMRI at 1.5T with a finger tapping paradigm and mental movement simulating foot flexion on the dominant side were performed before, 3 months, and 1 year after start of cITBa. fMRI data processing was carried out using FMRI Expert Analysis Tool (FEAT), part of FSL. A second-level analysis was carried out using FLAME stages 1 and 2. The level of spasticity was assessed with the Modified Ashworth scale (MAS).

Results

Continuous ITB significantly decreased limb spasticity in all the subjects (group MAS spasticity dropped from 3 to 0.3). The second-level analysis (Z > 1.6, cluster significance threshold p =0.05) revealed increased activation of the primary sensorimotor cortex of the foot between baseline and 3 months, and 3 months and 1 year.

Conclusion

Increased sensorimotor cortex activation with spasticity reduction after cITBa may reflect distant functional reorganization because of long-term mediated neuroplastic changes in the sensorimotor cortex. Better understanding of modulation of brain function in SCI after cITBa may influence the field of neurorehabilitation.

Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes in acute spinal cord injury interventional trials

Introduction: Spasticity is a common consequence of spinal cord injury (SCI), estimated to affect up to 93% of people living with SCI in the community. Problematic spasticity affects around 35% people with SCI spasticity. The early period after injury is believed to be the most opportune time for neural plasticity after SCI. We hypothesize that clinical interventions in the early period could reduce the incidence of spasticity. To address this, we evaluated the spasticity outcomes of clinical trials with interventions early after SCI.Methods: We performed a systematic review of the literature between January 2000 and May 2021 to identify control trials, in humans and animals, that were performed early after SCI that included measures of spasticity in accordance with PRISMA guidelines.Results: Our search yielded 1,463 records of which we reviewed 852 abstracts and included 8 human trial peer-reviewed publications and 9 animal studies. The 9 animal trials largely supported the hypothesis that early intervention can reduce spasticity, including evidence from electrophysiological, behavioral, and histologic measures. Of the 8 human trials, only one study measured spasticity as a primary outcome with a sample size sufficient to test the hypothesis. In this study, neuromodulation of the spinal cord using electric stimulation of the common peroneal nerve reduced spasticity in the lower extremities compared to controls.Conclusion: Given the prevalence of problematic spasticity, there is surprisingly little research being performed in the early period of SCI that includes spasticity measures, and even fewer studies that directly address spasticity. More research on the potential for early interventions to mitigate spasticity is needed.

Neuromodulation as a basic platform for neuroprotection and repair after spinal cord injury

Spinal cord injury (SCI) is one of the most challenging medical issues. Spasticity is a major complication of SCI. A combination of spinal cord stimulation, new methods of neuroprotection and biomedical cellular products provides fundamentally new options for SCI treatment and rehabilitation. The paper attempts to critically analyze the effectiveness of using these procedures for patients with SCI, suggesting a protocol for a step-by-step personalized treatment of SCI, based on continuity of modern conservative and surgical methods. The study argues the possibility of using neuromodulation as a basis for rehabilitating patients with SCI.

An implantable device to treat multiple sclerosis: A discrete choice experiment on patient preferences in three European countries

BACKGROUND

Persons with multiple sclerosis (MS) take their treatment via pills, injections or infusions. A novel mode of disease-modifying treatment administration, an implantable device, is under development. This study determined MS patient preferences for three modes of first-line treatment administration (implant, pills, injectables), and trade-offs regarding treatment characteristics.

METHODS

A survey including a discrete choice experiment was conducted among MS patients in the Netherlands, France, and the United Kingdom. Respondents had to repeatedly choose between various treatment scenarios with four treatment characteristics: risk of relapse, reduction of disease progression, risk of side effects and mode of administration. Data was analysed using a panel latent class logit model.

RESULTS

Based on the preferences of 753 MS patients (response rate 7%: 753/11202), two latent classes were identified (class probability of 74% vs 26%). Persons with relapsing-remitting MS and who administered medication via injections generally preferred any treatment over no treatment. Patients who could walk without an aid were more likely to prefer no treatment. Reducing disease progression was the most important treatment characteristic class 1. Mode of administration was the most important characteristic in class 2. Patients were willing to accept an increase in risk of relapse and disease progression to get their treatment via an implant rather than injections. Predicted uptake was the highest for the implant, followed by pills, injections, and no treatment.

CONCLUSION

We found that a drug-delivery implant could be a potential addition to the MS treatment landscape: MS patients are willing to trade-off risk of relapse and disease progression for an implant, and predicted uptake for an implant is relatively high.

Dosing Patterns In Treatment of Disabling Spasticity With Intrathecal Baclofen

PURPOSE

The aim of this study was to describe and analyze dosing patterns for patients with ITB treatment over time and to identify possible subgroups demonstrating diversity in patterns.

DESIGN

A retrospective design.

METHODS

For 81 patients from six different hospitals, baclofen doses from the first 2 years of treatment were identified using medical records. Line graphs of each patient's doses were analyzed and grouped based on similarities in dosing pattern.

FINDINGS

The analyses of the dosing patterns resulted in four different subgroups classified as stable, slow increase, rapid increase, and fluctuating.

CONCLUSION

The results highlight the clinical challenge of predicting dose development over time.

CLINICAL RELEVANCE TO REHABILITATION NURSING

This study provides rehabilitation healthcare professionals with a better understanding of intrathecal baclofen dose development. Illustrations of the four subgroups can be used as an educational tool for patients, family, and caregivers.

Rehabilitation of Spinal Cord Injury: WFNS Spine Committee Recommendations

Spinal cord injury (SCI) is accompanied by a significant number of complications associated with damage to the spinal cord, gross functional impairments leading to limited self-care and movement, leading to a high level of disability, social and psychological maladaptation of the patients. Besides, pain and spasticity negatively affect rehabilitation programs. This search was conducted in PubMed/MEDLINE database. All studies published in English language (n = 16,297) were considered for inclusion. Of all studies evaluating rehabilitation in SCI patients (n = 80) were included. Based on the literature review the faculty of the WFNS Spine Committee created statements covering different aspects of the contemporary rehabilitation process of the SCI patients. The prepared statements were subjected to discussions, followed by anonymous voting process by the members of the WFNS Spine Committee. As result of the diccussions and the voting process the statements were modified and published as recommendations of the WFNS Spine Committee. The care for the SCI has gone a long way from the times after the World War II when these patients were considered hopeless in terms of any functional recovery, to the contemporary comprehensive rehabilitation programs. The rehabilitation is important part of the modern comprehencive treatment of SCI patients nowadays. The current manuscript reflects different aspects of the contemporary rehabilitaton process and decision makings, which were discussed by the faculty of the WFNS Spine Committee resulting in issuing of the following recommendations.

Long-term effect of intrathecal baclofen treatment on bone health and body composition after spinal cord injury: A case matched report

BACKGROUND

Severe spasticity may negatively impact functionality and quality of life after spinal cord injury (SCI). Intrathecal baclofen treatment (IBT) is effectively used to manage severe spasticity and reduce comorbidities. However, long-term IBT may have a negative effect on bone mineral content (BMC), bone mineral density (BMD) and body composition (such as percentage fat mass and lean body mass). We demonstrated the negative effects of long-term IBT use in a single case compared with two non-IBT users.

CASE SUMMARY

A 46-year old Caucasian male Veteran (case) with a 21 year history of complete tetraplegia (complete C6 SCI) was implanted with IBT for 20 years. The case was matched to two participants with different time since injuries [2 (match 1) and 13 (match 2) years] without IBT. Knee BMC and BMD at the epiphysis and metaphysis of the distal femur and proximal tibia were evaluated using dual knee and the dual femur modules of GE Lunar iDXA software. Total and leg body composition assessments were also conducted for the three participants. Potential effect of long-term IBT was demonstrated by changes in BMD, consistent with bone demineralization, at the distal femur and proximal tibia and changes in percentage fat mass and lean mass of legs. The case showed 113% lower BMD at the distal femur, and 78.1% lower at the proximal tibia compared to match 1, moreover the case showed 45% lower BMD at the distal femur, and no observed changes at the proximal tibia compared to match 2. The case had 27.1% and 16.5% greater leg %fat mass compared to match 1 and match 2, respectively. Furthermore, the case had 17.4% and 11.8% lower % leg lean mass compared to match 1 and match 2, respectively.

CONCLUSION

Long-term IBT may impact bone health and body composition parameters in persons with complete SCI. It may be prudent to encourage regular screening of individuals on long-term IBT considering the prevalence of osteoporosis related fractures, cardiovascular diseases, and metabolic disorders in this population.

A First-in-Human, Phase I Study of Neural Stem Cell Transplantation for Chronic Spinal Cord Injury

We tested the feasibility and safety of human-spinal-cord-derived neural stem cell (NSI-566) transplantation for the treatment of chronic spinal cord injury (SCI). In this clinical trial, four subjects with T2-T12 SCI received treatment consisting of removal of spinal instrumentation, laminectomy, and durotomy, followed by six midline bilateral stereotactic injections of NSI-566 cells. All subjects tolerated the procedure well and there have been no serious adverse events to date (18-27 months post-grafting). In two subjects, one to two levels of neurological improvement were detected using ISNCSCI motor and sensory scores. Our results support the safety of NSI-566 transplantation into the SCI site and early signs of potential efficacy in three of the subjects warrant further exploration of NSI-566 cells in dose escalation studies. Despite these encouraging secondary data, we emphasize that this safety trial lacks statistical power or a control group needed to evaluate functional changes resulting from cell grafting.

Efficiency and Safety of Aftercare With Intrathecal Baclofen on Location

OBJECTIVES

Patients with intractable spasticity treated with intrathecal baclofen (ITB) need regular evaluation and aftercare in an outpatient clinic or pain clinic setting. Logistically, this can be challenging. A solution could be to perform treatment at the patient's home setting. In the Netherlands, a project of the Dutch Healthcare Authority was initiated to deliver ambulatory ITB-related services via a home-based Ambulant Care Clinic. This aftercare is performed by nurse practitioners (NP) with support from a medical specialist. The scope of the study was to investigate the efficiency and safety of ITB-care for patients with severe disabling spasticity in their home setting.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data. Patients with congenital or acquired spasticity were treated with ITB (1st April 2011 to January 1st 2016) using an implanted programmable pump system were referred to the home-based Ambulant Care Clinic by various neuromodulation centers in the Netherlands. All study parameters were a part of the standard intake and follow-up documentation.

RESULTS

Of the 900 patients treated with ITB in the Netherlands, 239 were referred to the home-based Ambulant Care Clinic and included in this study. Mean age was 45.5 (range 7-82) years; 52% lived at home; the average satisfaction score was 9 (scale 0-10); and 0.29% had (serious) adverse events (60% of clinical manifestations were prevented by remote double-check control). Certifications for patient safety and quality standards were obtained.

CONCLUSIONS

The concept of ITB aftercare on location demonstrated efficacy and safety in the described setting. For troubleshooting, close collaboration with a neuromodulation center is necessary and can be arranged in chain-based care.

A review of novel trends in management of canine spinal cord injury

Severe spinal cord injury (SCI) causing significant morbidity and mortality remains one of the most challenging problems in both human and veterinary medicine. Due to the restricted regeneration potential of the central nervous system (CNS) in mammals, the neurological deficit caused by spinal cord (SC) injury is permanent, and no therapeutic measures are able to completely restore neurological functions either in primates or in non-primate animals with traumatic tetraparesis/tetraplegia or paraparesis/paraplegia. The constant progress in the understanding of pathophysiologic events developing after spinal cord trauma constitute an unremitting inspiration for neuroscientists and health care professionals to test novel medicaments and treatment strategies to cope with this situation. Recent experimental studies and preclinical trials have delivered promising results. The aim of this review is a presentation of generally accepted methods of management of dogs with SCI as well as a report on new therapeutic modalities, and comment on their potential for clinical translation. The research strategy involved a search of PubMed, Medline, and ISI Web of Science from January 2010 to December 2018 using the terms “spinal cord injuryˮ and “management of spinal traumaˮ in the English language literature. References from selected papers were also scanned and evaluated for relevance.

Managing Chronic Non-Malignant Pain in the Elderly: Intrathecal Therapy

Intrathecal drug delivery (IDD) was first described in 1981 by Onofrio, who used a pump for continuous and intrathecal delivery of morphine to treat cancer pain. Over the following four decades, many reports supported this treatment method with implanted pumps for cancer and non-cancer pain. To date, more than 300,000 pumps for pain therapy and spasticity have been implanted worldwide. This article reviews current knowledge regarding intrathecal opioid therapy, focusing particularly on the use of IDD in elderly patients. Current literature is presented, and the arguments in favor of and against this therapy in elderly patients are discussed.

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

BACKGROUND

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

In Silico Methods for the Discovery of Orthosteric GABAB Receptor Compounds

The GABAB receptor (GABAB-R) is a heterodimeric class C G protein-coupled receptor comprised of the GABAB1a/b and GABAB2 subunits. The endogenous orthosteric agonist γ-amino-butyric acid (GABA) binds within the extracellular Venus flytrap (VFT) domain of the GABAB1a/b subunit. The receptor is associated with numerous neurological and neuropsychiatric disorders including learning and memory deficits, depression and anxiety, addiction and epilepsy, and is an interesting target for new drug development. Ligand- and structure-based virtual screening (VS) are used to identify hits in preclinical drug discovery. In the present study, we have evaluated classical ligand-based in silico methods, fingerprinting and pharmacophore mapping and structure-based in silico methods, structure-based pharmacophores, docking and scoring, and linear interaction approximation (LIA) for their aptitude to identify orthosteric GABAB-R compounds. Our results show that the limited number of active compounds and their high structural similarity complicate the use of ligand-based methods. However, by combining ligand-based methods with different structure-based methods active compounds were identified in front of DUDE-E decoys and the number of false positives was reduced, indicating that novel orthosteric GABAB-R compounds may be identified by a combination of ligand-based and structure-based in silico methods.

[Long-term results of chronic intrathecal baclofen treatment in patients with spasticity and secondary dystonia]

AIM

To estimate the efficacy of intrathecal treatment with baclofen (ITB) in spasticity and dystonia.

MATERIAL AND METHODS

Two groups of patients have been operated: 19 patients with spinal spasticity and 33 patients with cerebral spasticity (cerebral palsy). After baclofen screening test, the Synchromed2 (Medtronic) was implanted. The level of muscle tone was assessed by the Ashworth scale. The locomotion was assessed by GMFM 88 and Arens scale. The dystonia was assessed by the BFM scale. Follow-up was performed 3, 6 and 12 months after the operation and yearly after that. The duration of the follow-up ranged from 2 to 9 years.

RESULTS

ITB led to a significant decrease in leg spasticity in both groups of patients (p<0.001). The dynamics of spasticity was more significant in the first group compared to the second group (2.77 and 2.07 points, respectively (p<0.0031)). The dynamics of muscle tone in arms was lesser then in legs (p<0.0022). The positive clinical dynamics in patients with secondary dystonia was minimal (BFM from 65±17 to 60±19). Increasing of ITB daily dose was required to maintenance the clinical effect in most patients. The loss of ITB effect was noted in 5% of patients.

CONCLUSION

ITB was more effective in patients with spinal spasticity. The influence of ITB on the secondary dystonia was lesser then on the spasticity. The dynamic of the muscle tone was more significant in legs than in arms. The loss of ITB effect can be observed in some cases after the operation despite the positive result of baclofen screening-test.

Assessment of quality of life in relation to spasticity severity and socio-demographic and clinical factors among patients with spinal cord injury

Objective: To assess the impact of spasticity severity as well as socio-demographic and clinical factors on quality of life (QOL) and to identify factors predicting poor QOL among patients with spinal cord injury (SCI)Design: Descriptive cross-sectional study.Setting: Tertiary care clinic in Istanbul, Turkey.Participants: A total of 110 patients with SCI (mean (SD) age: 43.8 (14.7) years, 58.2% were males) were enrolled.Assessments: The American Spinal Injury Association (ASIA) Impairment Scale (AIS), Modified Ashworth Scale (MAS) and Turkish version of the World Health Organization Quality of life questionnaire (WHOQOL-BREF) were utilized to determine the SCI category, severity of spasticity and QOL scores, respectively.Outcome measures: The WHOQOL-BREF scores were evaluated with respect to the severity of spasticity, aetiology and duration of SCI, AIS category and method of bladder management.Results: The mean (SD) physical health (41.9 (15.3) vs. 46.5 (10.9), P = 0.029), social relationships (45.6 (20.2) vs. 53.8 (17.3), P = 0.025) and total WHOQOL-BREF scores were significantly lower in patients with more severe spasticity. Multivariate linear regression analysis revealed that severity of spasticity was a significant predictor of decreased WHOQOL-BREF total scores, physical domain scores and social relations domain scores by 11.381 (P = 0.007), 11.518 (P = 0.005) and 17. 965 (P = 0.004), respectively.Conclusion: In conclusion, addressing QOL in relation to severity of spasticity for the first time among Turkish SCI patients, our findings revealed a negative impact of the spasticity severity on the WHOQOL-BREF scores, particularly for physical health and social relationship domains.

Nature of the Non-traumatic Spinal Cord Injury Literature: A Systematic Review

Background: Non-traumatic SCI (NTSCI) etiologies represent a markedly heterogeneous cluster of conditions defined within the consensus NTSCI taxonomy. This meta-analysis assembles evidence about the occurrence of NTSCI and its clinical outcomes with respect to 6 research domains. Purpose: To investigate the quality and quantity of clinical NTSCI evidence published in the peer reviewed literature with reference to prognosis, diagnosis, intervention, process of care, methodology, and qualitative approaches. Methods: PubMed and MEDLINE OVID MeSH heading searches were conducted for 5 common-language NTSCI descriptors. Filters were English language and Entrez date (1997-2016). Filters also controlled for case reports, editorials or errata, and invited reviews. NTSCI etiologies incorrectly classified, animal studies, and multidimensional mapping studies were excluded. Full texts were retrieved and ranked for evidence quality according to PRISMA statement guidelines, or PEDro criteria. Data were extracted and simple descriptive statistics applied. Results: The search terms non traumatic and non-traumatic SCI retrieved 282 articles, with 39 duplicates. After exclusion of 117 articles: Level 1V (60); NTSCI incorrectly evaluated (14); publication bias (2); non-English language (1); and animal experiments (1), 126 titles/abstracts were screened and ranked against criteria. Of the 8 papers allocated for full-text review, a subset of 3 articles was ranked level 1A (1) or level 11A (2); mean PEDro score 5.75±0.5. Reasons for full-text exclusions (5) were NTSCI incorrectly classified (1) and statistical limitations (4). Of the 6 domains, prognostics had adequate data yield (86) for evidence synthesis (4.8% ranked level 1A, or 11A). Notable evidence gaps were identified in qualitative (1), methodological (2), and diagnostic (8) domains. Conclusion: Therapeutic approaches require an evidence-based understanding of the distinct contexts in which NTSCI occurs, especially in less resourced settings. Our findings underscore the need for qualitative and quantitative research on the occurrence of NTSCI in all contexts.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia

OBJECTIVE

Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief.

METHODS

All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status.

RESULTS

Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores.

CONCLUSIONS

Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Effect of prescription medications on erectile dysfunction

Erectile dysfunction (ED) affects about 50% of men in the USA and is primarily attributed to physiological (organic) and psychological causes. However, a substantial portion of men suffer from ED due to iatrogenic causes. Common medications such as antihypertensives, non-steroidal anti-inflammatory drugs and antacids may cause ED. Physicians should be aware of the various prescription medications that may cause ED to properly screen and counsel patients on an issue that many may feel too uncomfortable to discuss. In this review, we discuss the physiology, data and alternative therapies for the ED caused by medications.

Training an Actor-Critic Reinforcement Learning Controller for Arm Movement Using Human-Generated Rewards

Functional Electrical Stimulation (FES) employs neuroprostheses to apply electrical current to the nerves and muscles of individuals paralyzed by spinal cord injury to restore voluntary movement. Neuroprosthesis controllers calculate stimulation patterns to produce desired actions. To date, no existing controller is able to efficiently adapt its control strategy to the wide range of possible physiological arm characteristics, reaching movements, and user preferences that vary over time. Reinforcement learning (RL) is a control strategy that can incorporate human reward signals as inputs to allow human users to shape controller behavior. In this paper, ten neurologically intact human participants assigned subjective numerical rewards to train RL controllers, evaluating animations of goal-oriented reaching tasks performed using a planar musculoskeletal human arm simulation. The RL controller learning achieved using human trainers was compared with learning accomplished using human-like rewards generated by an algorithm; metrics included success at reaching the specified target; time required to reach the target; and target overshoot. Both sets of controllers learned efficiently and with minimal differences, significantly outperforming standard controllers. Reward positivity and consistency were found to be unrelated to learning success. These results suggest that human rewards can be used effectively to train RL-based FES controllers.

Percutaneous Endoscopic Gastrostomy in a Patient With Continuous Intrathecal Baclofen Infusion Therapy

Percutaneous endoscopic gastrostomy (PEG) is the method of choice in patients requiring long-term enteral tube feeding. In patients with intrathecal baclofen infusion therapy (IBT) pump implantation, infection via the skin and soft tissue may be an issue of concern. The introducer technique for gastrostomy tube insertion may be useful in reducing the risk of peristomal infection. Although the presence of a PEG tube has been reported as a risk factor for implantation site infection (for newly inserted IBT pumps), whether existing IBT pumps are at risk for infection during or after the placement of a PEG tube is not clear. We report a case where PEG was successfully performed using the introducer technique on a patient with an IBT pump implant.

Determination of ED50 of hydromorphone for postoperative analgesia following cesarean delivery

BACKGROUND

Morphine is the most common opioid injected into the intrathecal space for postoperative analgesia following cesarean delivery, but ongoing medication shortages have resulted in limited availability. One proposed morphine alternative is hydromorphone. Studies investigating its use in post-cesarean analgesia are limited. This study was conducted to determine the median effective dose of intrathecal hydromorphone 12h postpartum.

METHODS

Twenty healthy women undergoing elective cesarean delivery were recruited into this study. Hydromorphone doses were determined using the up-down sequential method. The study dose of hydromorphone started at 6μg and was raised or lowered by 2μg depending on the 12-h efficacy of the preceding participant's dose. Pain scores of <3/10 were considered successful and the subsequent patient received a lower dose. Participants received 0.5% bupivacaine 12.5mg, fentanyl 25μg, and the study dose of hydromorphone as a single intrathecal injection.

RESULTS

Ten of 20 participants reported an effective hydromorphone dosage 12h post-injection. The median effective hydromorphone dosage was 4.6μg (95% CI 3.72 to 5.48μg) based on participants' reported visual analog pain scores of <3/10. No significant side effects or adverse outcomes were observed.

CONCLUSION

Intrathecal hydromorphone may be an effective alternative to morphine for post-cesarean pain management. The amount of intrathecal hydromorphone necessary to provide analgesia at 12h postoperatively may be significantly lower than doses currently in use. Further research should be performed to identify the optimal dose of intrathecal hydromorphone for post-surgical pain relief.

Cost-effectiveness of Intrathecal Baclofen Therapy in severe refractory non-focal disabling spasticity: a Spanish hospital perspective

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.

Unusual placement of intrathecal baclofen pumps: report of two cases

Intrathecal baclofen delivery via implantable pump represents an important modality for symptomatic relief in patients with chronic spasticity. Pumps are routinely implanted subcutaneously in the anterior abdominal wall. We describe two unusual cases where skin-related complications necessitated revision surgery in order to relocate the pump to alternative sites. The first patient was an international power canoeist, whose strenuous exercise programme interfered with his pump’s original siting. The second patient was a cachectic university student with a history of cerebral palsy, who maintained low body mass despite attempted weight gain. The relocation of these two intrathecal devices to the medial compartment of the right thigh and right iliac fossa, respectively, is described.

Management of chronic spinal cord dysfunction

PURPOSE OF REVIEW

Both acute and chronic spinal cord disorders present multisystem management problems to the clinician. This article highlights key issues associated with chronic spinal cord dysfunction.

RECENT FINDINGS

Advances in symptomatic management for chronic spinal cord dysfunction include use of botulinum toxin to manage detrusor hyperreflexia, pregabalin for management of neuropathic pain, and intensive locomotor training for improved walking ability in incomplete spinal cord injuries.

SUMMARY

The care of spinal cord dysfunction has advanced significantly over the past 2 decades. Management and treatment of neurologic and non-neurologic complications of chronic myelopathies ensure that each patient will be able to maximize their functional independence and quality of life.

Spinal cord injury - there is not just one way of treating it

In the last century, research in the field of spinal cord trauma has brought insightful knowledge which has led to a detailed understanding of mechanisms that are involved in injury- and recovery-related processes. The quest for a cure for the yet generally incurable condition as well as the exponential rise in gained information has brought about the development of numerous treatment approaches while at the same time the abundance of data has become quite unmanageable. Owing to an enormous amount of preclinical therapeutic approaches, this report highlights important trends rather than specific treatment strategies. We focus on current advances in the treatment of spinal cord injury and want to further draw attention to arising problems in spinal cord injury (SCI) research and discuss possible solutions.

Intrathecal pain pumps: indications, patient selection, techniques, and outcomes

Intrathecal drug delivery represents an advanced modality for refractory chronic pain patients as well as intractable spasticity. This article reviews the advantages and indications for intrathecal therapy, as well as recommendations for proper patient selection using a multidisciplinary team to provide a global assessment of the impact of chronic pain on the patient's well-being. The goals and expectations of trialing are discussed alongside advantages and disadvantages of several trialing techniques. A discussion of outcomes is presented for patients with chronic pain due to both malignant and nonmalignant causes.