Effect of Intrathecal Baclofen Bolus Injection on Temporospatial Gait Characteristics in Patients With Acquired Brain Injury

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

Background

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

Objective

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

Case report

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

Conclusion

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

The impact of intrathecal baclofen on the ability to walk: A systematic review

OBJECTIVE

Intrathecal baclofen (ITB) is an effective treatment for lower limb spasticity. In ambulatory patients with spasticity, there is a justifiable concern that ITB treatment may compromise ambulatory function by reducing the heightened muscle tone, thereby unmasking underlying muscle weakness. ITB is hence offered with reservation in ambulant patients. In this article, we review the literature surrounding the effect of ITB therapy on ambulatory function in patients with concurrent spasticity and discuss the key findings.

DATA SOURCES

A literature search of ProQuest Medline and EBSCO CINAHL databases was performed.

REVIEW METHOD

Inclusion criteria included (a) studies reporting the effect of ITB in adult ambulatory patients; (b) studies with an intervention of screening test trial via either bolus injections or continuous infusion tests; and (c) studies with an intervention of ITB pump implantation. Seventeen eligible studies were identified and two authors independently assessed the study quality using the risk of bias in nonrandomised studies of interventions tool (ROBINS-I).

RESULTS

Seventeen studies were included, with a total of 534 participants. Most of the patients remain ambulatory after ITB treatment, accompanied by improvements in gait speed and reduction in spasticity.

CONCLUSION

ITB therapy when administered in carefully selected ambulatory patients with spasticity is not associated with loss of ambulatory function.

A New Definition of Poststroke Spasticity and the Interference of Spasticity With Motor Recovery From Acute to Chronic Stages

The relationship of poststroke spasticity and motor recovery can be confusing. "True" motor recovery refers to return of motor behaviors to prestroke state with the same end-effectors and temporo-spatial pattern. This requires neural recovery and repair, and presumably occurs mainly in the acute and subacute stages. However, according to the International Classification of Functioning, Disability and Health, motor recovery after stroke is also defined as "improvement in performance of functional tasks," i.e., functional recovery, which is mainly mediated by compensatory mechanisms. Therefore, stroke survivors can execute motor tasks in spite of disordered motor control and the presence of spasticity. Spasticity interferes with execution of normal motor behaviors ("true" motor recovery), throughout the evolution of stroke from acute to chronic stages. Spasticity reduction does not affect functional recovery in the acute and subacute stages; however, appropriate management of spasticity could lead to improvement of motor function, that is, functional recovery, during the chronic stage of stroke. We assert that spasticity results from upregulation of medial cortico-reticulo-spinal pathways that are disinhibited due to damage of the motor cortex or corticobulbar pathways. Spasticity emerges as a manifestation of maladaptive plasticity in the early stages of recovery and can persist into the chronic stage. It coexists and shares similar pathophysiological processes with related motor impairments, such as abnormal force control, muscle coactivation and motor synergies, and diffuse interlimb muscle activation. Accordingly, we propose a new definition of spasticity to better account for its pathophysiology and the complex nuances of different definitions of motor recovery.

Knee Muscle Stretch Reflex Responses After an Intrathecal Baclofen Bolus in Neurological Patients With Moderate-to-Severe Hypertonia

OBJECTIVES

To examine the prevalence, onset threshold, and response magnitude of stretch reflex response (SRR) in the knee extensors and flexors before and after an intrathecal baclofen (ITB) bolus injection in patients with moderate-to-severe hypertonia.

MATERIALS AND METHODS

SRRs were elicited by reciprocal passive knee extension/flexion movements at preset angular velocities of 5, 60, 120, 180, 240, and 300°/s using an isokinetic dynamometer and recorded with surface electromyographic (EMG) electrodes placed over the knee extensors and flexors in 53 neurologic patients before and at 2.5 and 5 hours after an ITB injection via lumbar puncture. Outcome measures included the number of patients with presence/absence of SRRs, the number of SRRs per session, SRR onset threshold angle and velocity, and response magnitudes (peak EMG and area under the EMG curve) for each muscle. Pre-post comparisons were completed using the Fisher's exact and Wilcoxon signed rank tests.

RESULTS

For both knee extensors and flexors, the proportion of patients with present SRRs (p < 0.0001) and the number of SRRs per session (p ≤ 0.027) decreased from pre- to post-ITB. The threshold velocity significantly increased post-injection in both muscles (p ≤ 0.001) without significant changes in the threshold angle. The response magnitudes significantly decreased in the knee extensors (p ≤ 0.016) but not the knee flexors after the injection.

CONCLUSIONS

The prevalence and threshold velocity of SRR emerged as the most robust and practical parameters for assessing hyperreflexia during ITB bolus trial that can complement clinical assessment of muscle hypertonia.

Intrathecal Therapies

Intrathecal baclofen therapy is a well-established technique for spasticity management. This article briefly reviews the pharmacology of intrathecal baclofen as well as customary approach for utilization of this targeted drug delivery concept. Following these descriptions, four unusual presentations will be described, including the need for initial trialing, patient-directed boluses during chronic intrathecal baclofen therapy, use of medications other than baclofen for intrathecal therapy in spastic patients, and intraventricular baclofen delivery. These hypothetical cases are provided in an effort to expand the use of targeted drug delivery to larger population of spastic patients.

Gait Impairments in Patients Without Lower Limb Hypertonia Early Poststroke Are Related to Weakness of Paretic Knee Flexors

OBJECTIVE

To describe gait characteristics of patients without clinical evidence of lower limb hypertonia within 2 months of stroke and explore the relationship between gait and residual motor function.

DESIGN

Cohort study.

SETTING

Motion analysis laboratory in a tertiary-care free-standing rehabilitation hospital.

PARTICIPANTS

Consecutive sample of 73 eligible inpatients (first-known stroke <2 months postonset, walking independently, modified Ashworth score of 0 in the paretic lower limb) and 27 healthy controls (N=100).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Gait speed, stride and step lengths and cadences, stance time, single-support and double-support times, and associated symmetry measures in patients at self-selected normal speed and controls at very slow speed (51.1±32.6 cm/s and 61.9±21.8 cm/s, respectively, P=.115); Fugl-Meyer lower extremity motor score (FM-LE) and isometric knee flexion and extension strength in patients.

RESULTS

Except the stride/step cadence, all temporospatial parameters significantly differed between the stroke and control participants. Furthermore, significantly greater asymmetries were found in the patients for the overall stance time, initial double-support and single-support times, and step cadence, reflecting smaller values in the paretic than nonparetic limb. Most temporospatial parameters moderately to strongly correlated with the gait speed (|r|: .72-.94, P<.0001), FM-LE (|r|: .42-.62, P≤.0005), and paretic knee flexor strength (|r|: .47-.57, P≤.0004).

CONCLUSIONS

Gait of patients without clinical evidence of lower limb hypertonia within 2 months of stroke is characterized by many temporospatial deviations and asymmetries. The self-selected normal gait speed, FM-LE, and paretic knee flexor strength can discriminate gait impairments in these patients shortly before inpatient discharge. It remains to be determined whether the observed relationships between paretic knee flexor strength and gait measures warrant the development of interventions for strengthening of the paretic knee flexors in order to improve gait early poststroke.

The effect of continuous intrathecal baclofen therapy on ambulatory children with cerebral palsy

The effect of a continuous intrathecal infusion of baclofen (CITB) was retrospectively studied in 19 ambulatory children with cerebral palsy (aged 12.4±4.9 years at CITB initiation). The mean clinical follow-up was 5.1±2.4 years and the mean follow-up gait analysis was 2.8±1.9 years. Spastic cerebral palsy diagnosis [14 (74%)] was most frequent. Most patients [11 (58%)] were Gross Motor Function Classification System level III. CITB significantly improved muscle tone and knee flexion at initial contact (P<0.05), but it did not lead to improved gait speed or gross motor function.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Relationship between activation of ankle muscles and quasi-joint stiffness in early and middle stances during gait in patients with hemiparesis

It is unclear whether muscle contraction is necessary to increase quasi-joint stiffness (QJS) of the ankle joint during gait in patients with hemiparesis. The purpose of the present study was to investigate the relationship between QJS and muscle activation at the ankle joint in the stance phase during gait in patients with hemiparesis. Spatiotemporal and kinetic gait parameters and activation of the medial head of the gastrocnemius (MG), soleus (SOL), and tibialis anterior (TA) muscles were measured using a 3-dimensional motion analysis system and surface electromyography, in 21 patients with hemiparesis due to stroke and 10 healthy individuals. In the early stance, the QJS on the paretic side (PS) of patients was greater than that on the non-PS (p<0.05) and not significantly correlated with activation of the three muscles. In the middle stance, the QJS on the PS was lower than that on the non-PS (p<0.05) and that on the right side of controls (p<0.001), which was positively correlated with activation of the MG (r=0.51, p<0.05) and SOL (r=0.49, p<0.05). In the patients with hemiparesis, plantarflexor activation may not contribute to QJS in the early stance. On the other hand, QJS in the middle stance may be attributed to activation of the MG and SOL. Our findings suggest that activation of the MG and SOL in the middle stance on the PS may require to be enhanced to increase QJS during gait in patients with hemiparesis.

Gait mechanics in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by the frequent association of disease outside the lung. The objective of this study was to determine the presence of biomechanical gait abnormalities in COPD patients compared to healthy controls while well rested and without rest.

METHODS

Patients with COPD (N = 17) and aged-matched, healthy controls (N = 21) walked at their self-selected pace down a 10-meter walkway while biomechanical gait variables were collected. A one-minute rest was given between each of the five collected trials to prevent tiredness (REST condition). Patients with COPD then walked at a self-selected pace on a treadmill until the onset of self-reported breathlessness or leg tiredness. Subjects immediately underwent gait analysis with no rest between each of the five collected trials (NO REST condition). Statistical models with and without covariates age, gender, and smoking history were used.

RESULTS

After adjusting for covariates, COPD patients demonstrated more ankle power absorption in mid-stance (P = 0.006) than controls during both conditions. Both groups during NO REST demonstrated increased gait speed (P = 0.04), stride length (P = 0.03), and peak hip flexion (P = 0.04) with decreased plantarflexion moment (P = 0.04) and increased knee power absorption (P = 0.04) as compared to REST. A significant interaction revealed that peak ankle dorsiflexion moment was maintained from REST to NO REST for COPD but increased for controls (P < 0.01). Stratifying by disease severity did not alter these findings, except that step width decreased in NO REST as compared to REST (P = 0.01). Standardized effect sizes of significant effects varied from 0.5 to 0.98.

CONCLUSIONS

Patients with COPD appear to demonstrate biomechanical gait changes at the ankle as compared to healthy controls. This was seen not only in increased peak ankle power absorption during no rest but was also demonstrated by a lack of increase in peak ankle dorsiflexion moment from the REST to the NO REST condition as compared to the healthy controls. Furthermore, a wider step width has been associated with fall risk and this could account for the increased incidence of falls in patients with COPD.

Effect of the Intrathecal Baclofen Screening Test on the Spatiotemporal Gait Motion Parameters of Patients with Cervical Spinal Cord Injuries Who Exhibited Diffuse Spasticity: A Report of Three Cases

We examine the quantitative changes in the gait motion of patients with cervical spinal cord injuries (CSCIs) before and after the intrathecal baclofen (ITB) screening test. The subjects were three patients with CSCI, who exhibited spasticity in the lower extremities. They could all walk 10 or more meters with/without aids. All patients were subjected to the ITB screening test, in which they had gabalon (50 μg) injected into their spinal column via paramedian puncture at the L3–4 level. The subjects had their ankle clonus; patellar tendon reflex; and modified Ashworth scale, Berg balance scale, Spinal Cord Independence Measure, and 10 -meter walk test (10MWT) assessed before and 5 hours after the ITB screening test. At 5 hours after the ITB screening test, all of the patients exhibited decreased spasticity in static position, and improved balance. There were no differences in the abilities of any of the patients to perform ADL. One patient did not change the spatiotemporal gait motion parameters (walking time, step count, and step length in the 10MW T). Therefore, the pomp implantation for ITB therapy was not performed. Two patients who had suffered CSCI more than 20 years ago exhibited a reduced walking time, increased step count, and step length. Out of the two patients one received the pomp of implantation after ITB screening test, and the other was planned to operate. The spatiotemporal gait motion parameters might be one of the useful tests to decide the pomp implantation for CSCI patients who hope improvement of gait ability.

Effect of Intrathecal Baclofen Bolus Injection on Ankle Muscle Activation During Gait in Patients With Acquired Brain Injury

Background. Intrathecal baclofen (ITB) bolus injection effectively decreases spinal excitability but the impact on lower limb muscle activation during gait has not been thoroughly investigated. Objective. Examine activation of medial gastrocnemius (MG) and tibialis anterior (TA) muscles during gait before and after ITB bolus injection in patients with resting hypertonia after acquired brain injury. Methods. Lower extremity Ashworth score, temporospatial gait parameters, characteristics of the linear relationship between electromyogram (EMG) and lengthening velocity (LV) in MG during stance, and the duration and magnitude of TA-MG coactivation were assessed before and at 2, 4, and 6 hours after a 50-µg ITB injection via lumbar puncture in 8 hemorrhagic stroke and 11 traumatic brain injury subjects. Results. Temporospatial gait parameters did not significantly differ across the evaluation points ( P ≥ .170). However, Ashworth score ( P < .001), frequency and gain of significant positive EMG-LV slope ( P ≤ .020), and duration of TA-MG coactivation ( P ≤ .013) significantly decreased in the more-affected leg after ITB bolus. EMG changes were not significantly different between patients who did (n = 10) and did not (n = 9) increase gait speed after the injection. The timing of the largest decrease in Ashworth score and the largest decrease in EMG parameters coincided in 36% of cases, on average. Conclusions. ITB bolus injection alters the activation of MG and TA during gait. However, the changes in muscle activation are not closely related to the changes in gait speed or resting muscle hypertonia. The analysis of ankle muscle activation during gait better characterizes the response to ITB bolus injection than gait kinematics.

Consciousness recovery induced by intrathecal baclofen administration after subarachnoid hemorrhage -two case reports-

Two patients with subarachnoid hemorrhage recovered consciousness after intrathecal baclofen administration using an implanted intrathecal baclofen pump delivering 50 microg per day using a simple infusion mode. Intrathecal baclofen resulted in significant reduction of spasticity 3 months after the implantation. Case 1 was reduced to a completely bedridden state with spasticity and could slightly move her fingers following commands. However, the patient could eat food and wash her face with minimal assistance at 3 months after the implantation, and could stand up in the parallel bars with assistance and speak several words at 8 months. Case 2 was in a completely bedridden state at 10 months after onset and could neither drink water nor follow instructions. However, the patient became oriented and could eat by herself within 3 to 4 weeks of implantation. She could walk with a cane and use the stairs with minimal assistance at 2 and 3 months after implantation. The patient could speak fluently within 6 months of implantation. Flatulence and dysuria happened during the screening test, but these symptoms were not repeated after implantation of a pump-catheter-system and continuous intrathecal baclofen infusion. Continuous intrathecal baclofen infusion caused both improvement in muscle tone and spasms and consciousness recovery from the vegetative state. This therapy is a strong candidate treatment for patients with spasticity and consciousness disturbance.

Role of early surgical decompression of the intradural space after cervical spinal cord injury in an animal model

BACKGROUND

The role of decompressing the intradural space through a durotomy as a treatment option for acute traumatic cervical spinal cord injury has not been explored in an animal model, to our knowledge. We sought to determine the role of durotomy and duraplasty in the treatment of acute cervical spinal cord injury and its effects on inflammation, scar formation, and functional recovery.

METHODS

Seventy-two adult female Sprague-Dawley rats were assigned to three groups: contusion injury alone, contusion injury with a decompressive durotomy, and contusion injury with a decompressive durotomy followed by placement of a dural allograft. A mild (200-kdyn [2-N]) contusive injury was delivered to the exposed spinal cord at C5. The injured segment was reexposed four hours after injury, and a durotomy with decompression was performed. When a dural allograft was used it was affixed to the surrounding intact dura with use of a fibrin sealant. The Grip Strength Meter was used to assess forelimb function. Animals were killed at two and four weeks, and immunohistochemical analysis was performed to assess scar formation, inflammatory cell infiltration, and lesional volume.

RESULTS

Immunohistochemical analysis revealed increased scar formation, cavitation, and inflammatory response in the animals treated only with a decompressive durotomy. Relative to the group with a contusion injury alone, the animals treated with a durotomy followed by a dural allograft had decreased cavitation and scar formation. Lesional volume measurements showed a significantly increased cavitation size at four weeks in both the contusion-only (mean and standard deviation, 12.6 +/- 0.5 mm(3)) and durotomy-only (15.1 +/- 1 mm(3)) groups relative to the animals that had received a dural allograft following durotomy (6.8 +/- 1.4 mm(3)).

CONCLUSIONS

Functional recovery after acute cervical spinal cord injury was better in animals treated with decompression of the intradural space and placement of a dural allograft than it was in animals treated with decompression alone. These functional data correlated directly with histological evidence of a decrease in spinal cord cavitation, inflammation, and scar formation.

Intrathecal baclofen use in adults with cerebral palsy

Intrathecal baclofen (ITB) is an effective treatment for both spasticity and dystonia in people with cerebral palsy (CP). Its use is becoming increasingly common. ITB is typically associated with fewer side effects than the oral form of the product, but there are risks related to the hardware needed for intrathecal delivery. Much of what has been reported in the literature about ITB is based on experience with children or groups of children and adults; few reports exclusively address its use in adults with CP. These reports indicate that muscle tone is consistently reduced, but there is some variability in functional outcomes. Few well-controlled studies have been done. Controversies remain concerning ITB, including whether a trial is needed before pump implantation, proper catheter tip placement, and programming options, as well as whether it contributes to the development or progression of scoliosis. These and other unanswered questions should be addressed in a systematic way.

Motor impairment rehabilitation post acquired brain injury

OBJECTIVE

We sought to investigate the efficacy of treatment strategies used to manage motor impairments following acquired brain injury (ABI) in order to provide guidance for clinical practice based on the best available evidence.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on pharmacological, non-pharmacological, and exercise interventions available for motor impairments post ABI. The efficacy of a given intervention was classified as strong (supported by two or more randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).

RESULTS

Thirty-six studies examining a variety of treatment approaches for motor impairments and activity limitations following ABI were evaluated. The majority of interventions are only supported by limited evidence. However, there is strong evidence that serial casting does reduce ankle plantar contractures due to spasticity of cerebral origin, and strong evidence also suggests that partial body weight supported gait training does not provide any added benefit over conventional gait training. There is also moderate evidence to support the use of functional fine motor control retraining to improve motor coordination, tizanidine for upper and lower extremity spasticity, and specific sit-to-stand training to improve functional ability. There is also moderate evidence that casting alone is as effective as casting and Botulinum toxin injections for plantar contractures.

CONCLUSIONS

Although there are a variety of treatment strategies to manage motor impairments and activity limitations following ABI, most are only supported by limited evidence pointing to the need for studies of improved methodological quality in this area.

Intrathecal baclofen in the treatment of spasticity, dystonia and vegetative disorders

Baclofen (beta-p-chlorophenyl-GABA) binds to a number of spinal and cerebral sites and depresses the excitability of motor neurons. Intrathecal administration induces much higher CSF concentrations compared to the limited passage through the blood-brain barrier after oral administration. The development of reliable implanted pumps allows long-term intrathecal baclofen treatment (ITB). Baclofen is mainly an antispastic drug and the main indication of ITB is generalized lower limb spasticity in spinal cord injury and multiple sclerosis. The side-effects are due to either drug over-dose or withdrawal and to malfunctions of the implanted device (disconnections of the catheter, infections, etc.). Large numbers of patients have been treated over the past twenty years. More recently, baclofen has been used in the treatment of spasticity of cerebral origin, and in the treatment of other motor disorders, mainly dystonia. The results in cerebral palsy are promising and ITB's role will probably grow in the management of the movement disorders of these children. Further studies are required on the exact site of action, on the possible association with other drugs, especially clonidine and on the development of sustained release formulations.

Efficacy of intrathecal baclofen delivery in the management of severe spasticity in upper motor neuron syndrome

In the treatment of patients with severe spasticity, intrathecal administration of baclofen (ITB) was introduced in order to exert its effect directly at the receptor sites in the spinal cord, and have better therapeutic efficacy with smaller drug doses compared to oral antispasmodic medications. Apart from our own research in Groningen, a review is performed to present and discuss the efficacy of ITB in patients with spasticity and hypertonia as symptoms of the upper motor neuron syndromes. The majority of the ITB studies describe proven efficacy in the reduction of spasticity and spasms in short-term and long-term follow-up. Functional improvements in daily care, hygiene, pain, etc are described but not often with reliable and validated instruments. A few studies reported significant improvement in walking performance in ambulant patients. The studies that have been done on the efficacy of ITB in relation to quality of life (QOL) showed some evidence of improvement. Future research is needed on fine tuning in the ITB therapy using functional assessment instruments.

Intrathecal baclofen in current neuromodulatory practice: established indications and emerging applications

Intrathecal baclofen (ITB) has evolved into a standard treatment for severe spasticity of both spinal and cerebral origin. The accumulated promising data from reported series of patients receiving ITB therapy together with the fact that spastic hypertonia commonly coexists with other neurological disorders have constituted a solid basis for offering this kind of treatment to patients suffering from other movement disorders. These include motor disorders such as dystonia, amyotrophic lateral sclerosis, status dystonicus, Hallervorden-Spatz disease, Freidreich's ataxia, "stiff-man" syndrome, but also vegetative states after revere brain trauma, anoxic encephalopathy or other pathology and more recently, various chronic pain syndromes. In this article, on the basis of the established applications of ITB therapy, we review the important emerging indications of this rewarding neuromodulation method and attempt to identify its future potential beneficial role in other chronic and otherwise refractory neurological disorders.

Intérêt de la pompe à baclofène dans le traitement de la spasticité chez l'hémiplégique: à propos d'un cas

OBJECTIVE

To determine whether intrathecal administration of baclofen reduced spastic hypertonia in a hemiplegic patient after hemorrhagic stroke.

METHODS

A trial of intrathecal administration of baclofen was carried out with bolus injections of 50 and 75 microg baclofen and clinical and functional evaluation (Aschworth, articular amplitude) before and after injection in a patient with hemorrhagic stroke. After these trials, the placement of a pump was proposed to the patient.

RESULTS

Aschworth score improved from 4 to 3 on triceps, quadriceps and adductus, with functional improvement of gait quality and perimeter and position in the wheelchair. Cephalgia, present before the treatment, increased after the implantation of the pump. The patient had some ejaculation trouble with the treatment, as well as some neurological pains after the pump implantation but experienced no effect on upper limbs.

DISCUSSION

The intrathecal administration of baclofen has been used in some studies of hemiplegic patients, with reduced spasticity and improved the kinematic parameters of gait. The intrathecal baclofen administration could complement other treatment to control spasticity after stroke.

CONCLUSION

Intrathecal baclofen administration could be an interesting complementary therapeutic among patients with important spasticity not controlled by the usual treatments.

Consensus panel guidelines for the use of intrathecal baclofen therapy in poststroke spastic hypertonia

Intrathecal baclofen (ITB) therapy has been increasingly employed for the management of poststroke spastic hypertonia, a complication that can lead to deformity, discomfort, and exacerbation of motor impairments. Because its use in stroke is not as established as other indications, ITB therapy has not been subjected to rigorous investigation. There is limited evidence to guide clinicians regarding application of this therapy in this patient population. This article aims to review the available scientific literature and the opinion of several experts on the topic. It will also describe the recommendations of these experts with regard to addressing common clinical situations that may influence treatment decisions in the stroke population.

Intrathecal Baclofen Management of Poststroke Spastic Hypertonia: Implications for Function and Quality of Life

OBJECTIVES

To evaluate the impact of intrathecal baclofen (ITB) on function and quality of life (QOL) and to obtain efficacy and safety data in poststroke spastic hypertonia.

DESIGN

Prospective open-label multicenter trial with follow-up at 3 and 12 months.

SETTING

Twenty-four stroke treatment centers in the United States.

PARTICIPANTS

Ninety-four stroke participants (age range, 24-82 y) with spastic hypertonia. Seventy-four participants underwent ITB pump implantation.

INTERVENTION

Participants were implanted with an ITB pump.

MAIN OUTCOME MEASURES

FIM instrument and QOL (Sickness Impact Profile [SIP]) changes, spastic hypertonia (Ashworth Scale), and safety.

RESULTS

FIM scores improved overall in repeated-measures analysis of variance (ANOVA) (P = .005) and by 3.00 +/- 7.69 (P = .001) at 3 months and by 2.86 +/- 10.13 (P = .017) at 12 months. Significant improvements in SIP scores were noted overall (repeated-measures ANOVA, P < .001) and at 3 (P = .003) and 12 months (P < .001). The combined average Ashworth Scale score of the upper and lower limbs decreased by 1.27 +/- 0.76 (P < .001) at 3 months and by 1.39 +/- 0.73 (P < .001) at 12 months from baseline, which was significant overall (repeated-measures ANOVA, P<.001). Strength in the unaffected side did not change overall (repeated-measures ANOVA, P = .321) or at either 3 (P = .553) or 12 months (P = .462). Minimal adverse events and device complications were reported.

CONCLUSIONS

There was significant improvement in function, QOL, and spastic hypertonia at 3 and 12 months after implant, without adversely affecting muscle strength of the unaffected limbs. Data suggest that ITB therapy is a safe and efficacious treatment for spastic hypertonia resulting from stroke.

Delay in initiation and termination of tibialis anterior contraction in lower-limb hemiparesis: relationship to lower-limb motor impairment and mobility

OBJECTIVE

To assess the relationship between delays in initiation and termination of tibialis anterior contraction in the hemiplegic lower limb and clinical measures of lower-limb motor impairment and mobility.

DESIGN

Cross-sectional correlational study.

SETTING

Outpatient rehabilitation clinic of an academic medical center.

PARTICIPANTS

Convenience sample of 22 chronic stroke survivors with lower-limb hemiparesis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Delays in initiation and termination of tibialis anterior electromyographic activity during isometric contraction, lower-limb Fugl-Meyer Assessment (FMA), and Modified Emory Functional Ambulation Profile (mEFAP).

RESULTS

The affected lower limb exhibited significantly longer delays in initiation and termination of tibialis anterior contraction relative to the unaffected limb. Delay in termination of 3-second tibialis anterior contraction of the affected limb correlated significantly with the FMA and mEFAP. However, delay in initiation of tibialis anterior contraction did not correlate with clinical measures.

CONCLUSIONS

Delay in termination of muscle activity in the hemiparetic lower limb may have important clinical implications, but delay in initiation did not correlate with clinical measures. Controlled, interventional trials are needed to demonstrate a cause and effect relationship.

Long–term intrathecal baclofen therapy in ambulatory patients with spasticity

BACKGROUND

Intrathecal baclofen (ITB) is an effective treatment for severe spasticity. In ambulatory patients with spasticity, it is possible that ITB treatment may compromise ambulatory function by unmasking underlying muscle weakness. This retrospective study is designed to determine the long-term ambulatory function in patients receiving ITB.

METHODS

Thirty-six patients with severe spasticity previously screened for response to ITB were implanted with programmable pumps that allowed for continuous infusion of ITB. Patients were followed after implantation from 1 to 13 years.

RESULTS

All 36 patients had decreased spasticity and retained ambulatory function. Three of the 36 patients eventually became paraplegic related to underlying disease progression.

CONCLUSION

ITB therapy may be used in selected ambulatory patients with spasticity and is not associated with loss of ambulatory function.