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Schmidt J, Düvel JA, Elkenkamp S, Greiner W. Comparing the EQ-5D-5L and stroke impact scale 2.0 in stroke patients: an analysis of measurement properties. Health Qual Life Outcomes 2024; 22:45. [PMID: 38835023 DOI: 10.1186/s12955-024-02252-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/20/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Stroke has evolved to become a chronic disease and a major public health challenge. To adequately capture the full disease burden of stroke patients, the assessment of health-related quality of life (HRQoL) and thus the performance of respective measures is increasingly relevant. The aim of this analysis was to compare the measurement properties of two self-report instruments, the EQ-5D-5L and the Stroke Impact Scale 2.0. METHODS The data used for the analysis was derived from a quasi-experimental case management study for mildly to moderately affected incident stroke and transient ischemic attack (TIA) patients aged ≥ 18 in Germany. Data was collected patient-individually at 3, 6 and 12 months after initial stroke. The EQ-5D-5L and SIS 2.0 were compared in terms of feasibility, ceiling and floor effects, responsiveness and known-groups validity (Kruskal-Wallis H and Wilcoxon rank-sum test). RESULTS A response for all three follow-ups is available for n = 855 patients. The feasibility of the EQ-5D-5L is determined as good (completion rate: 96.4-96.6%, ≥ one item missing: 3.2 - 3.3%), whereas the SIS 2.0 is moderately feasible (overall completion rate: 44.9-46.1%, ≥ one item missing in domains: 4.7 - 28.7%). The SIS 2.0 shows substantial ceiling effects in comparable domains (physical function: 10.4 - 13%, others: 3.5-31.3%) which are mainly larger than ceiling effects in the EQ-5D-5L index (17.1-21.5%). In terms of responsiveness, the EQ-5D-5L shows small to moderate change while the SIS 2.0 presents with moderate to large responsiveness. The EQ-5D-5L index, mobility, usual activities and Visual Analogue Scale show known-groups validity (p < 0.05). Content-related domains of the SIS 2.0 show known-groups validity as well (p < 0.05). However, it is compromised in the emotion domain in both measures (p > 0.05). CONCLUSIONS The EQ-5D-5L seems to be slightly more suitable for this cohort. Nonetheless, the results of both measures indicate limited suitability for TIA patients. Large-scale studies concerning responsiveness and known-groups validity are encouraged. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register, retrospective registration on 21.09.2022. REGISTRATION ID DRKS00030297.
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Affiliation(s)
- Juliana Schmidt
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany.
| | - Juliane Andrea Düvel
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Svenja Elkenkamp
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
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2
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Kakodkar P, Girgis H, Nabhan P, Chee SS, Tu A. Efficacy of Selective Dorsal Rhizotomy and Intrathecal Baclofen Pump in the Management of Spasticity. Adv Tech Stand Neurosurg 2022; 45:379-403. [PMID: 35976458 DOI: 10.1007/978-3-030-99166-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Neurosurgical indications and interventions provided in the management of spasticity have evolved significantly over time. Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pumps have been used to improve mobility, reduce lower extremity spasticity, and increase quality of life in patients with various diagnoses. METHODS Studies describing ITB and SDR outcomes in adult and pediatric patients were identified from Medline and Embase databases. Only publications between January 1990 to January 2021 were included. Combinations of search terms 'Selective Dorsal Rhizotomy', 'Selective Posterior Rhizotomy', 'functional posterior rhizotomy', 'intrathecal baclofen pump', and 'spasticity' were used. Only studies in English language and those that included parameters for lower extremity outcome (i.e., spasticity, ambulation) were included. Only studies describing follow-up 12 months or greater were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS Two hundred and ninety publications between January 1990 to January 2021 were identified. Of these, 62 fit inclusion and exclusion criteria for a total of 1291 adult and 2263 patients. Etiologies in adult and pediatric populations varied substantially with multiple sclerosis, cerebral palsy, and trauma comprising the majority of causes for spasticity in adult patients. In pediatric patients, cerebral palsy was the predominant etiology of spasticity. While outcomes after SDR and ITB varied, both are effective for long-term tone reduction. SDR appeared to have a greater effect on function compared to baseline when comparing relatively similar subgroups. The complication rates for either intervention were significant; ITB had a much greater incidence of wound and hardware adverse events, whereas SDR was associated with a not insignificant incidence of new bladder or sensory deficit. CONCLUSION ITB and SDR have demonstrated efficacy and utility for tone reduction in a variety of conditions. The selection of a specific intervention may have a variety of determining features including the etiology of spasticity, age of patient, as well as balancing benefit and complication profiles of each technique. Appropriate patient selection is essential for providing optimal patient outcomes.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Republic of Ireland
| | - Hidy Girgis
- Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada
| | - Perla Nabhan
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Sharini Sam Chee
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
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Gross R, Verduzco-Gutierrez M, Draulans N, Zimerman M, Francisco G, Deltombe T. Module 3: Surgical management of spasticity. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2022. [DOI: 10.4103/2349-7904.347809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hodge JO, Brandmeir CL, Brandmeir NJ. Neuromodulation Therapies for Spasticity Control: Now and Beyond. Neurol India 2021; 68:S241-S248. [PMID: 33318358 DOI: 10.4103/0028-3886.302464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.
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Affiliation(s)
- Johnie O Hodge
- Department of Neurosurgery, Rockefeller Neuroscience Institute, Morgantown, WV, United States
| | - Cheryl L Brandmeir
- Department of Human Performance, West Virginia University, Morgantown, WV, United States
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Rockefeller Neuroscience Institute, Morgantown, WV, United States
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5
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Tomaras MC, Simmons SF, Schnelle JF, Charles D, Hacker ML. The Minimum Data Set: An Opportunity to Improve Spasticity Screening. J Am Med Dir Assoc 2020; 22:608-612. [PMID: 32893138 DOI: 10.1016/j.jamda.2020.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.
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Affiliation(s)
- Miranda C Tomaras
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN.
| | | | | | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
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6
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Abstract
Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26-86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.
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Comi G, Solari A, Leocani L, Centonze D, Otero‐Romero S, Amadeo R, Amato MP, Bertolotto A, Boffa L, Brichetto G, Comola M, Ghezzi A, Lus G, Marrosu MG, Molteni F, Patti F, Pozzilli C, Rovaris M, Saccà F, Sessa E, Solaro C, Trojano M, Trompetto C, Zaffaroni M. Italian consensus on treatment of spasticity in multiple sclerosis. Eur J Neurol 2019; 27:445-453. [DOI: 10.1111/ene.14110] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 09/27/2019] [Indexed: 11/30/2022]
Affiliation(s)
- G. Comi
- Institute of Experimental NeurologyUniversità Vita‐Salute, Ospedale S. Raffaele Milan Italy
| | - A. Solari
- Unit of NeuroepidemiologyFondazione IRCCS Istituto Neurologico C. Besta Milan Italy
| | - L. Leocani
- Institute of Experimental NeurologyUniversità Vita‐Salute, Ospedale S. Raffaele Milan Italy
| | - D. Centonze
- Unit of NeurologyIRCCS Neuromed Pozzilli Italy
- Laboratory of Synaptic ImmunopathologyDepartment of Systems MedicineTor Vergata University Rome Italy
| | - S. Otero‐Romero
- MS Centre of Catalonia (Cemcat), Dept. Neurology/NeuroimmunologyPreventive Medicine Dept.Vall d'Hebron University Hospital Barcelona Spain
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Creamer M, Cloud G, Kossmehl P, Yochelson M, Francisco GE, Ward AB, Wissel J, Zampolini M, Abouihia A, Calabrese A, Saltuari L. Effect of Intrathecal Baclofen on Pain and Quality of Life in Poststroke Spasticity. Stroke 2019; 49:2129-2137. [PMID: 30354975 PMCID: PMC6116794 DOI: 10.1161/strokeaha.118.022255] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intrathecal baclofen (ITB) is an effective treatment for managing patients with severe poststroke spasticity, who can experience continued pain and decline in their quality of life (QoL). SISTERS (Spasticity In Stroke-Randomized Study) was a randomized, controlled, open-label, multicenter, phase 4 study to evaluate ITB therapy versus conventional medical management (CMM) with oral antispastic medications for treatment of poststroke spasticity. Methods- Poststroke patients with spasticity in ≥2 extremities and an Ashworth Scale score of ≥3 in ≥2 affected lower extremity muscle groups were randomized (1:1) to ITB (N=31) or CMM (N=29). Both treatment arms received physiotherapy throughout. The primary outcome was the change in average Ashworth Scale score in the lower extremities of the affected side from baseline to month 6. Here, we report results for secondary outcomes: pain via the Numeric Pain Rating Scale, health-related QoL by the EuroQol-5 dimensional 3 level utility score and health status visual analog scale score, stroke-specific QoL, and patient satisfaction. Analyses were performed on an intention-to-treat basis. Results- We observed significant treatment effects in favor of ITB over CMM for changes from baseline to month 6 in Numeric Pain Rating Scale scores for actual pain (ITB versus CMM: mean, -1.17 [SD, 3.17] versus 0.00 [3.29]; median, -1.00 versus 0.00; P=0.0380) and least pain (mean, -1.61 [2.29] versus 0.24 [3.07]; median, -1.00 versus 0.00; P=0.0136), and EuroQol-5 dimensional 3 level utility scores (mean, +0.09 [0.26] versus +0.01 [0.16]; median, +0.07 versus 0.00; P=0.0197). Between-group differences were not statistically significant for EuroQol-5 dimensional 3 level visual analog scale, stroke-specific QoL summary, or Numeric Pain Rating Scale worst pain scores, although ITB patients showed greater numeric improvements from baseline during follow-up. More ITB patients than CMM patients (73% versus 48%) were satisfied with the spasticity reduction at month 6. Conclusions- These data support that ITB therapy is associated with improvements in pain and QoL in poststroke patients. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01032239.
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Affiliation(s)
- Michael Creamer
- From the Central Florida Pain Relief Centers, Orlando (M.C.)
| | - Geoffrey Cloud
- St. George's University Hospitals NHS Foundation Trust, London, United Kingdom (G.C.).,Department of Neurology, Alfred Health, Melbourne, VIC, Australia (G.C.)
| | - Peter Kossmehl
- Kliniken Beelitz GmbH Neurologische Rehabilitationsklinik, Beelitz-Heilstätten, Germany (P.K.)
| | - Michael Yochelson
- MedStar National Rehabilitation Hospital, Washington, DC (M.Y.).,Shepherd Center, Atlanta, GA (M.Y.)
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center and TIRR Memorial Hermann Hospital, Houston (G.E.F.)
| | - Anthony B Ward
- North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke-On-Trent, United Kingdom (A.B.W.)
| | - Jörg Wissel
- Neurological Rehabilitation and Physical Therapy, Department of Neurology, Vivantes Hospital Spandau, Berlin, Germany (J.W.)
| | - Mauro Zampolini
- USL Umbria 2, Department of Rehabilitation, Ospedale di Foligno, Perugia, Italy (M.Z.)
| | - Abdallah Abouihia
- Neuromodulation Clinical, Medtronic International, Tolochenaz, Switzerland (A.A., A.C.)
| | - Alessandra Calabrese
- Neuromodulation Clinical, Medtronic International, Tolochenaz, Switzerland (A.A., A.C.)
| | - Leopold Saltuari
- Abteilung für Neurologie Landeskrankenhaus Hochzirl, Austria (L.S.).,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy (L.S.)
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9
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Winter G, Beni-Adani L, Ben-Pazi H. Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management. J Child Neurol 2018; 33:734-741. [PMID: 30009656 DOI: 10.1177/0883073818785074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intrathecal baclofen is an expanding accepted treatment for children with cerebral palsy and other causes of spasticity and dystonia. The aims of this review are therefore to (1) delineate the clinical benefits of intrathecal baclofen therapy in pediatric spasticity and dystonia and (2) increase awareness of the potential complications and emergency management measures of intrathecal baclofen therapy. A current literature review demonstrates the benefits and complications of this minimally invasive device. Practical guides for recognizing acute conditions and management recommendations are included. Intrathecal baclofen is increasingly being used to help individuals attain realistic functional goals. Therefore, families and health care professionals should be aware of potential complications, symptoms, and emergency management.
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Affiliation(s)
- Gidon Winter
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
| | - Liana Beni-Adani
- 2 Pediatric Neurosurgery, Shaare Zedek Medical Center, Jerusalem
| | - Hilla Ben-Pazi
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
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10
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Chan DY, Chan SS, Chan EK, Ng AY, Ying AC, Li AC, Chiu CC, Cheung N, Mak W, Sun DT, Zhu CX, Poon W. Blessing or burden? Long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. SURGICAL PRACTICE 2018; 22:105-110. [PMID: 30147745 PMCID: PMC6099513 DOI: 10.1111/1744-1633.12308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/10/2018] [Indexed: 12/01/2022]
Abstract
AIM The intrathecal baclofen pump is an effective treatment for spasticity. However, long-term results have reported patients' dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. PATIENTS AND METHODS We conducted a 16-year retrospective cohort study of patients with spasticity treated with an intrathecal baclofen pump at a university hospital from 2000 to 2016. The primary outcome was the rate of infection per puncture for baclofen pump refill. Secondary outcomes included the incidence of other complications, such as running out of baclofen causing symptomatic withdrawal symptoms, pump mechanical failure, pump battery end of life and the need for pump replacement. The clinical outcome was assessed by the Modified Ashworth Scale (mAS). RESULTS In total, 340 follow-up episodes with pump refill procedures were recorded. The average interval between each pump refill was 57.3 days (±15.4 days). The average duration of admission for each pump refill was 4 h and 49 min (from 2 h 23 min to 10 h). There were two events with established infection after puncture for the refill, giving rise to an infection rate per puncture of 0.6 percent (2/340).For the long-term clinical outcome, at an average follow-up period of 7.6 years, the postoperative mAS for spasticity was 2.0 ± 0.756, which was significantly better than the preoperative mAS at 3.75 ± 0.462 (P = 0.001). CONCLUSION Long-term aftercare with baclofen pump refill was safe, with an infection rate of 0.6 per cent per puncture for each refill. Long-term intrathecal baclofen pump was effective in the treatment of spasticity with persistent significant improvement in the spasticity scale.
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Affiliation(s)
- David Yuen‐Chung Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Steve Sik‐Kwan Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Emily Kit‐Ying Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Amelia Yikjin Ng
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Aaron Chee‐Lun Ying
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ara Cheuk‐Yin Li
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Candy Ching‐Pik Chiu
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ning Cheung
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Wai‐Kit Mak
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - David Tin‐Fung Sun
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Cannon Xian‐Lun Zhu
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Wai‐Sang Poon
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
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11
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Ghareghani M, Zibara K, Sadeghi H, Farhadi N. Spasticity Treatment Ameliorates the Efficacy of Melatonin Therapy in Experimental Autoimmune Encephalomyelitis (EAE) Mouse Model of Multiple Sclerosis. Cell Mol Neurobiol 2018; 38:1145-1151. [PMID: 29497878 DOI: 10.1007/s10571-018-0580-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/20/2018] [Indexed: 01/06/2023]
Abstract
Multiple sclerosis (MS) is a progressive inflammatory demyelinating disease in the central nervous system (CNS). Melatonin is an effective treatment in MS patients and experimental autoimmune encephalomyelitis (EAE), a mouse model of MS. Melatonin secretion peaks at 2 AM, concomitant with the time at which the muscles are resting and the body is exerting its antioxidant activity. The current study was designed to investigate combination treatment of baclofen, a muscle relaxant drug, and melatonin in EAE mice. Results showed that melatonin (Mel) alone or in combination with baclofen (Bac + Mel) reduced clinical scores and demyelination by significantly increasing myelin oligodendrocyte glycoprotein (MOG) levels, a marker for mature oligodendrocytes, compared to EAE mice. Moreover, Mel or Bac + Mel therapy caused a significant increase in IL-4 serum levels, an anti-inflammatory cytokine, whereas IFN-γ serum levels, a pro-inflammatory cytokine, were significantly reduced. On the other hand, Mel or Bac + Mel caused a significant reduction in malondialdehyde (MDA) levels, a marker of oxidative stress, in comparison to EAE mice. In contrast, the activity of antioxidant enzymes catalase (CAT) and superoxide dismutase (SOD) was significantly increased in Mel and Bac + Mel groups. In summary, combination therapy improved clinical scores and tend to enhance the efficiency of melatonin treatment by further promoting remyelination, decreasing inflammation, and stimulating the activity of antioxidant enzymes, which suggests that prior spasticity treatment increases the efficacy of melatonin therapy in EAE mouse model of MS. Further experimental and clinical studies are needed to ensure the beneficial role of this combination strategy.
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Affiliation(s)
- Majid Ghareghani
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.,CERVO Brain Research Center, Quebec City, QC, G1J 2G3, Canada
| | - Kazem Zibara
- ER045, Laboratory of Stem Cells, PRASE, Biology Department, Faculty of Sciences, Lebanese University, Beirut, Lebanon
| | - Hossein Sadeghi
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Naser Farhadi
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.
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12
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Synnot A, Chau M, Pitt V, O'Connor D, Gruen RL, Wasiak J, Clavisi O, Pattuwage L, Phillips K. Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev 2017; 11:CD008929. [PMID: 29165784 PMCID: PMC6486165 DOI: 10.1002/14651858.cd008929.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI. OBJECTIVES To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI. SEARCH METHODS In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data. MAIN RESULTS We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes. AUTHORS' CONCLUSIONS The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.
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Affiliation(s)
- Anneliese Synnot
- Monash UniversityCochrane Australia, School of Public Health and Preventive MedicineL4 551 St Kilda RdMelbourneVictoriaAustralia3004
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Marisa Chau
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Veronica Pitt
- Australian & New Zealand Intensive Care Research Centre (ANZIC‐RC), Monash UniversityLevel 6, The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Denise O'Connor
- Monash UniversitySchool of Public Health and Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Jason Wasiak
- University of MelbourneMelbourne School of Health SciencesGrattan Street, ParkvilleMelbourneVictoriaAustralia
| | - Ornella Clavisi
- MOVE muscle, bone & joint health263‐265 Kooyong Rd ElsternwickMelbourneVICAustralia3185
| | - Loyal Pattuwage
- Centre for Evidence and ImplementationEast MelbourneVICAustralia3175
| | - Kate Phillips
- Monash UniversitySchool of Public Health & Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
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Aristedis R, Dimitrios P, Nikolaos P, Alexandros B. Intrathecal baclofen pump infection treated by adjunct intrareservoir teicoplanin instillation. Surg Neurol Int 2017; 8:38. [PMID: 28458952 PMCID: PMC5369255 DOI: 10.4103/sni.sni_418_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 01/23/2017] [Indexed: 11/30/2022] Open
Abstract
Background: The delivery of intrathecal baclofen via pumps is gaining increasing use in the management of intractable spasticity. One of the rare but devastating complications of this method is infection. In the majority of cases, removal of the device is required, despite appropriate intravenous antibiotic therapy. We report a case that highlights the use of intrareservoir teicoplanin to achieve sterilization of the infected pump system in a patient in whom removal of the pump was not an easy option. Case Description: We describe our experience on a patient with cerebral palsy in whom Staphylococcus epidermidis pump infection developed due to contamination of the infusion reservoir during refilling procedure, which was successfully sterilized in situ by the combined use of systemic antibiotics and intrareservoir coadministration of baclofen with teicoplanin. The infection was eradicated and baclofen therapy was continued uninterrupted. Conclusions: Removal of intrathecal baclofen pump is not necessary as the first measure in cases with mild clinical symptomatology. In view of the fact that pumps for intrathecal drug delivery are very costly, salvage of the device may be attempted in selected cases, although it is not generally recommended. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain treatment for spasticity, sterilize the pump reservoir and flow tubes, and effectively treat infections that develop during the use of these systems.
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Affiliation(s)
- Rovlias Aristedis
- Neurosurgical Department, Asclepeion General Hospital of Athens, Athens, Greece
| | | | - Paidakakos Nikolaos
- Neurosurgical Department, Asclepeion General Hospital of Athens, Athens, Greece
| | - Blionas Alexandros
- Neurosurgical Department, Asclepeion General Hospital of Athens, Athens, Greece
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Yue B, Brendel R, Lukitsch A, Prentice T, Doty B. Solubility and Stability of Baclofen 3 mg/mL Intrathecal Formulation and Its Compatibility With Implantable Programmable Intrathecal Infusion Systems. Neuromodulation 2016; 20:397-404. [DOI: 10.1111/ner.12535] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Baohua Yue
- Parenteral Delivery Systems R&D, Mallinckrodt Pharmaceuticals; Hazelwood MO USA
| | - Ron Brendel
- Parenteral Delivery Systems R&D, Mallinckrodt Pharmaceuticals; Hazelwood MO USA
| | - Amelia Lukitsch
- Parenteral Delivery Systems R&D, Mallinckrodt Pharmaceuticals; Hazelwood MO USA
| | | | - Brian Doty
- Parenteral Delivery Systems R&D, Mallinckrodt Pharmaceuticals; Hazelwood MO USA
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Boster AL, Adair RL, Gooch JL, Nelson MES, Toomer A, Urquidez J, Saulino M. Best Practices for Intrathecal Baclofen Therapy: Dosing and Long-Term Management. Neuromodulation 2016; 19:623-31. [PMID: 27433993 DOI: 10.1111/ner.12388] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 11/05/2015] [Accepted: 11/12/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intrathecal baclofen (ITB) therapy aims to reduce spasticity and provide functional control. METHOD An expert panel consulted on best practices. RESULTS Pump fill and drug delivery can be started intraoperatively, with monitoring for at least eight hours. Initiate with the 500 mcg/mL concentration. The starting daily dose should be twice the effective bolus screening dose, or the screening dose if the patient had a prolonged response (greater than eight hours) or negative reactions. Oral antispasmodics can be weaned, one drug at a time beginning with oral baclofen after ITB begins. Assessment should occur within 24 hours of a dose change. For adults, daily dose increases may be 5% to 15% once every 24 hours for cerebral-origin spasticity and 10% to 30% once every 24 hours for spinal-origin spasticity. Daily dose increases can be 5% to 15% once every 24 hours for children. Inpatients should be assessed at least every 24 hours and receive rehabilitation. Step dosing can be used for outpatients who cannot return daily. Dosing options include simple continuous dosing, variable 24-hour flex dosing, or regularly scheduled boluses. Patients/caregivers should understand the care plan, responsibilities, and possible side-effects. Low-reservoir alarm dates and refill schedules should be written down, along with emergency contact information. A higher concentration at refill can extend refill intervals, and a bridge bolus must be programmed. Time changes may affect flex dosing. Pump replacement should be scheduled at least three months in advance. CONCLUSIONS ITB dosing is multistep and individualized.
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Affiliation(s)
- Aaron L Boster
- Adult Neurology, OhioHealth Neurological Physicians, Columbus, OH, USA
| | - Roy L Adair
- Adult Physical Medicine & Rehabilitation, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Judith L Gooch
- Adult and Pediatric Physical Medicine & Rehabilitation, Utah Neuro Rehabilitation, Salt Lake City, UT, USA
| | - Mary Elizabeth S Nelson
- Adult Physical Medicine & Rehabilitation Nurse Practitioner, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Joe Urquidez
- Adult Physical Medicine & Rehabilitation, Physical Medicine & Neurotoxin Institute, Austin, TX, USA
| | - Michael Saulino
- Adult Physical Medicine & Rehabilitation, MossRehab, Elkins Park, PA, USA
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Boster AL, Bennett SE, Bilsky GS, Gudesblatt M, Koelbel SF, McManus M, Saulino M. Best Practices for Intrathecal Baclofen Therapy: Screening Test. Neuromodulation 2016; 19:616-22. [PMID: 27434115 DOI: 10.1111/ner.12437] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 02/24/2016] [Accepted: 03/02/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intrathecal baclofen (ITB) screening assesses response to a test dose of ITB on spasticity and function and identifies adverse reactions. METHOD An expert panel consulted on best practices after conducting an extensive literature search and conducting an online survey. RESULTS A successful trial may confirm predetermined goals, which may include improved mobility/positioning, decreased time/improved independence for activities, less home exercise, better wheelchair tolerance, decreased caregiver time, improved sleep, and reduced pain, or may modify goals and expectations. Individuals should not be tested in the presence of active medical issues (e.g., MS exacerbations, active urinary tract infection, nonhealing wounds). Oral antispasmodics can be weaned before trial if a goal is to eliminate them. The standard baclofen test dose is a 50-mcg bolus, 25 mcg in very small children or patients who rely on spasticity for mobility. Patients unresponsive to the standard dose may require 75 mcg or 100 mcg; 24 hours should elapse between bolus doses. Cardiopulmonary parameters should be checked frequently during the first two hours postinjection, and spasticity measures assessed at least twice within four hours. Observation continues until the patient is stable and recovers from hypertonia. Adverse events include spinal headaches, nausea/vomiting, urinary retention, hypotension, seizures, drowsiness/sedation, respiratory depression, and coma. Before implantation, team members must discuss starting dose, drug concentration, delivery mode, pump size and location, and catheter tip placement. Patients/caregivers should understand the commitment necessary for ITB therapy. CONCLUSIONS Screening helps identify appropriate candidates for ITB.
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Affiliation(s)
| | - Susan E Bennett
- State University of New York (SUNY) at Buffalo, Buffalo, NY, USA
| | | | - Mark Gudesblatt
- Brookhaven Memorial Hospital Medical Center, South Shore Neurologic Associates, Islip, NY, USA
| | | | - Maura McManus
- Alfred I DuPont Hospital for Children, The Sidney Kimmel Medical College, Thomas Jefferson University, Wilmington, DE, USA
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Otero-Romero S, Sastre-Garriga J, Comi G, Hartung HP, Soelberg Sørensen P, Thompson AJ, Vermersch P, Gold R, Montalban X. Pharmacological management of spasticity in multiple sclerosis: Systematic review and consensus paper. Mult Scler 2016; 22:1386-1396. [DOI: 10.1177/1352458516643600] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/01/2016] [Indexed: 11/16/2022]
Abstract
Background and objectives: Treatment of spasticity poses a major challenge given the complex clinical presentation and variable efficacy and safety profiles of available drugs. We present a systematic review of the pharmacological treatment of spasticity in multiple sclerosis (MS) patients. Methods: Controlled trials and observational studies were identified. Scientific evidence was evaluated according to pre-specified levels of certainty. Results: The evidence supports the use of baclofen, tizanidine and gabapentin as first-line options. Diazepam or dantrolene could be considered if no clinical improvement is seen with the previous drugs. Nabiximols has a positive effect when used as add-on therapy in patients with poor response and/or tolerance to first-line oral treatments. Despite limited evidence, intrathecal baclofen and intrathecal phenol show a positive effect in severe spasticity and suboptimal response to oral drugs. Conclusion: The available studies on spasticity treatment offer some insight to guide clinical practice but are of variable methodological quality. Large, well-designed trials are needed to confirm the effectiveness of antispasticity agents and to produce evidence-based treatment algorithms.
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Affiliation(s)
- Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain/Preventive Medicine and Epidemiology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Giancarlo Comi
- Neurological Department, Institute of Experimental Neurology (INSPE), Scientific Institute Hospital San Raffaele, University Vita-Salute San Raffaele, Milan, Italy
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alan J Thompson
- Department of Brain Repair & Rehabilitation, Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Patrick Vermersch
- Université Lille, INSERM, CHU Lille, Lille Inflammation Research International Center (LIRIC) UMR 995, Lille, France
| | - Ralf Gold
- Department of Neurology, Ruhr University, St. Josef-Hospital, Bochum, Germany
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
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Khurana SR, Garg DS. Spasticity and the use of intrathecal baclofen in patients with spinal cord injury. Phys Med Rehabil Clin N Am 2015; 25:655-69, ix. [PMID: 25064793 DOI: 10.1016/j.pmr.2014.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Muscle spasms and spasticity constitute a significant problem in patients with spinal cord injury, interfering with rehabilitation and leading to impairments in quality of life in addition to medical complications. Administration of intrathecal baclofen (ITB) is indicated when spasticity continues to produce a clinical disability despite trials of oral treatments and other alternatives in patients who have functional goals and/or pain without contractures. Severe spasticity of spinal origin has been shown to respond dramatically to long-term ITB when used in appropriate patients with spasticity.
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Affiliation(s)
- Seema R Khurana
- Department of Physical Medicine and Rehabilitation, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, CRB Room 948, Miami, FL 33136, USA.
| | - Deep S Garg
- Department of Physical Medicine and Rehabilitation, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, Miami, FL, USA
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The association of presurgery psychological symptoms with postsurgery pain among cancer patients receiving implantable devices for pain management. Support Care Cancer 2014; 22:2323-8. [PMID: 25082618 DOI: 10.1007/s00520-014-2219-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 03/12/2014] [Indexed: 02/03/2023]
Abstract
PURPOSE Psychological symptoms are a common part of the cancer pain experience, yet little is known about how these factors relate to implantable device outcomes in patients with cancer pain. The purpose of this study was to examine how psychological symptoms relate to implantable device outcomes in cancer pain management. METHODS We retrospectively examined the medical records of 79 cancer patients, collecting information on psychological symptoms and pain, as assessed on the Edmonton Symptom Assessment System. Data were collected prior to and at three points following the implantation of either a spinal cord stimulator or an intrathecal pump. RESULTS Pain was correlated with both anxiety, r = 0.39 (n = 74, p < 0.01), and depression, r = 0.38, (n = 75, p < 0.01), at the presurgery baseline. Results of linear mixed model (LMM) analysis indicated that neither baseline anxiety nor baseline depression main effects were significantly associated with pain at postimplant assessments, when adjusting for baseline pain, demographics, and clinical factors. However, the group-by-time interaction was significant for anxiety (beta = 0.223, p value = 0.037). The trajectory of pain scores over time differed by baseline anxiety scores, with pain scores increasing over time at a higher rate for those with a high baseline anxiety score, compared to those with low baseline anxiety scores. CONCLUSION Presurgery psychological symptoms should be considered, along with other medical, psychosocial, and individual characteristics in multidisciplinary treatment planning. Multidisciplinary care which includes aspects of mood management or supportive psychotherapy would likely be beneficial to cancer patients presenting with high psychological symptoms.
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Uchiyama T, Nakanishi K, Fukawa N, Yoshioka H, Murakami S, Nakano N, Kato A. Neuromodulation using intrathecal baclofen therapy for spasticity and dystonia. Neurol Med Chir (Tokyo) 2013; 52:463-9. [PMID: 22850493 DOI: 10.2176/nmc.52.463] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Intrathecal baclofen (ITB) therapy is a treatment for intractable spasticity due to a variety of causes. Continuous intrathecal administration of baclofen, an agonist of the inhibitory neurotransmitter γ-aminobutyric acid, inhibits excitation of motor neurons at the spinal level and thus suppresses spasticity. This therapy was introduced clinically in the Europe and the United States in the 1990s, and was finally approved by the Japanese Ministry of Health, Labour and Welfare in Japan in 2005. Clinical use has been permitted since 2006, and reports of therapeutic efficacy are now appearing in Japan. ITB therapy is a non-destructive treatment that enables administration of baclofen from an implantable pump under the control of a programmer, and represents an outstanding treatment method offering both reversibility and adjustability. Indications for ITB therapy have been expanding in recent years to include not only spasticity, but also various causes dystonia. And ITB therapy can greatly improve activities of daily living and quality of life, and this treatment is attracting attention as a neuromodulatory therapy that also affects metabolic and respiratory functions and even state of consciousness. We here report the surgical methods and therapeutic outcomes for 22 patients who underwent ITB therapy for spastic and dystonic patients in our hospital, together with an investigation of the effects on metabolic and respiratory functions.
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Affiliation(s)
- Takuya Uchiyama
- Department of Neurosurgery, Kinki University Faculty of Medicine, Osaka, Japan.
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21
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Delhaas EM, Beersen N, Redekop WK, Klazinga NS. Long-term outcomes of continuous intrathecal baclofen infusion for treatment of spasticity: a prospective multicenter follow-up study. Neuromodulation 2013; 11:227-36. [PMID: 22151100 DOI: 10.1111/j.1525-1403.2008.00170.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Long-term outcomes of 115 patients treated with continuous intrathecal baclofen infusion are reported. A prospective follow-up study was conducted in eight centers. Patients were followed up over a 12-month period. The follow-up scores on the three spasticity scales (Ashworth, spasm, and clonus scales) were significantly lower at every follow-up visit in comparison to the intake score, except for the clonus scale scores at 12 months. Improvements in health-related quality of life (EQ-5D) and functionality (SIP-68, functional independence measure) were small and nonsignificant. A significant reduction in severity of self-reported personal problems rating scale was observed. Sixty-six patients had no adverse events. Types of adverse events reported were wound complications (22%), catheter problems (36%), cerebrospinal fluid leakage (25%), and other complications (17%). Intrathecal baclofen reduces spasticity and severity of patient-reported problems but its effect on quality of life and functionality is less apparent. Improvements are desired in selection criteria, design of spinal catheters, and outcome scales.
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Affiliation(s)
- Elmar M Delhaas
- Amphia Hospital Breda, Breda, The Netherlands; Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Truini A, Barbanti P, Pozzilli C, Cruccu G. A mechanism-based classification of pain in multiple sclerosis. J Neurol 2013; 260:351-67. [PMID: 22760942 PMCID: PMC3566383 DOI: 10.1007/s00415-012-6579-2] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 05/31/2012] [Accepted: 06/03/2012] [Indexed: 12/30/2022]
Abstract
Pharmacological treatment of pain in multiple sclerosis (MS) is challenging due to the many underlying pathophysiological mechanisms. Few controlled trials show adequate pain control in this population. Emerging evidence suggests that pain might be more effectively classified and treated according to symptoms and underlying mechanisms. The new mechanism-based classification we propose here distinguishes nine types of MS-related pain: trigeminal neuralgia and Lhermitte's phenomenon (paroxysmal neuropathic pain due to ectopic impulse generation along primary afferents), ongoing extremity pain (deafferentation pain secondary to lesion in the spino-thalamo-cortical pathways), painful tonic spasms and spasticity pain (mixed pains secondary to lesions in the central motor pathways but mediated by muscle nociceptors), pain associated with optic neuritis (nerve trunk pain originating from nervi nervorum), musculoskeletal pains (nociceptive pain arising from postural abnormalities secondary to motor disorders), migraine (nociceptive pain favored by predisposing factors or secondary to midbrain lesions), and treatment-induced pains. Identification of various types of MS-related pain will allow appropriate targeted pharmacological treatment and improve clinical practice.
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Affiliation(s)
- A. Truini
- Department of Neurology and Psychiatry, Sapienza University, Viale Università 30, 00185 Rome, Italy
- Don Gnocchi Foundation, Milan, Italy
| | | | - C. Pozzilli
- Department of Neurology and Psychiatry, Sapienza University, Viale Università 30, 00185 Rome, Italy
- MS Center, S. Andrea Hospital, Rome, Italy
| | - G. Cruccu
- Department of Neurology and Psychiatry, Sapienza University, Viale Università 30, 00185 Rome, Italy
- San Raffaele IRCCS, Rome, Italy
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Hayes C, Jordan MS, Hodson FJ, Ritchard L. Ceasing intrathecal therapy in chronic non-cancer pain: an invitation to shift from biomedical focus to active management. PLoS One 2012; 7:e49124. [PMID: 23145093 PMCID: PMC3493492 DOI: 10.1371/journal.pone.0049124] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/08/2012] [Indexed: 01/08/2023] Open
Abstract
Objective To report long term experience (1997–2009) of intrathecal (IT) therapy for chronic non-cancer pain in the context of our team’s increasing emphasis on active management. Design Descriptive case series. Setting Australian tertiary multidisciplinary pain center, Hunter Integrated Pain Service (HIPS). Intervention This case series reports the changing use of IT implanted drug delivery systems (IDDSs) for chronic non-cancer pain over 13 years. Initially IT therapy was used selectively following multidisciplinary assessment and double blind IT trial. Typical therapy combined opioid with clonidine. Multidimensional management was offered. Treatment strategy changed in 2003 due to HIPS experience of limited therapeutic gains and equivocal support for IT therapy in the literature. Subsequently IT therapy was no longer initiated for non-cancer pain and those on established regimes were encouraged to shift to oral/transdermal opioids with greater emphasis on active management. Patient education and consultation were key elements. Where IT cessation was elective gradual dose reduction commenced as an outpatient. In elective and urgent cases ketamine infusion and oral clonidine were used during hospital admissions to cover the switch to oral/transdermal opioids. Over the study period transition occurred to a broader management framework in which IT therapy for chronic non-cancer pain was no longer supported by HIPS. Results 25 patients were managed using IDDSs; 8 implanted by HIPS and 17 by other teams. Dose escalation and adverse effects were common. 24 of 25 patients ceased IT therapy; 7 (29%) with urgent IDDS related complications, 16 (67%) electively and 1 due to an unrelated death. The remaining patient returned to her original team to continue IT therapy. One post-explantation patient transferred to another team to recommence IT therapy. The remainder were successfully maintained on oral/transdermal opioids combined with active management.
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Affiliation(s)
- Chris Hayes
- Hunter Integrated Pain Service, Newcastle, New South Wales, Australia.
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Abstract
INTRODUCTION Multiple sclerosis (MS) is an inflammatory, demyelinating, central nervous system disease that frequently causes pain. AREAS COVERED This article reviews the current literature and describes the therapeutic options for treating MS-related pain. The reader will be provided with current, evidence-based knowledge about the treatment of MS-related pain, and the review will take a practical approach to the various drugs for treating pain, including starting dose, titration and side effects. EXPERT OPINION Only cannabinoids have been assessed in randomized, controlled trials. Because of the concern regarding the risk of abuse and psychiatric adverse events, published guidelines as well as expert recommendations suggest using them as second-line therapy only. Hence, current treatment should be based on the general principles for treating peripheral neuropathic pain, taking into account drug-induced adverse effects.
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Affiliation(s)
- Andrea Truini
- University of Rome-La Sapienza, Department of Neurology and Psychiatry, Viale Università 30, 00185 Rome, Italy.
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Bensmail D, Marquer A, Roche N, Godard AL, Lofaso F, Quera-Salva MA. Pilot Study Assessing the Impact of Intrathecal Baclofen Administration Mode on Sleep-Related Respiratory Parameters. Arch Phys Med Rehabil 2012; 93:96-9. [DOI: 10.1016/j.apmr.2011.08.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 08/19/2011] [Accepted: 08/20/2011] [Indexed: 10/14/2022]
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Zdolsek HA, Olesch C, Antolovich G, Reddihough D. Intrathecal baclofen therapy: benefits and complications. JOURNAL OF INTELLECTUAL & DEVELOPMENTAL DISABILITY 2011; 36:207-213. [PMID: 21830852 DOI: 10.3109/13668250.2011.595707] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Spasticity and dystonia in children with cerebral palsy has been treated with intrathecal baclofen therapy (ITB) at the Royal Children's Hospital, Melbourne, Australia (RCH) since 1999. METHODS The records of children having received or still receiving ITB during the period September 1999 until August 2005 were studied to evaluate complications and side effects. Parents answered a questionnaire focused on the health and functional impact in the children. RESULTS There were 18 first insertions of pumps, 6 removals, and 4 reinsertions. The longest treatment was 5 years and 11 months and was still ongoing. Seventeen complications occurred in 14 out of 18 children. Despite the high complication rate and the lack of significant functional improvement, 11 out of 12 parents agreed that ITB was beneficial. CONCLUSION ITB treatment at RCH over the years has resulted in some complications, mostly occurring shortly after pump insertion. For the majority of children there are substantial benefits.
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Affiliation(s)
- Helena Aniansson Zdolsek
- Department of Developmental Medicine, Royal Children's Hospital, and University of Melbourne, Melbourne, Australia
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Morton RE, Gray N, Vloeberghs M. Controlled study of the effects of continuous intrathecal baclofen infusion in non-ambulant children with cerebral palsy. Dev Med Child Neurol 2011; 53:736-41. [PMID: 21707598 DOI: 10.1111/j.1469-8749.2011.04009.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To measure changes in children with severe spastic cerebral palsy (CP) after continuous intrathecal baclofen (ITB) infusion over 18 months and to compare the results with those of a comparison group awaiting treatment. METHOD Thirty-eight children with severe spastic CP considered suitable for ITB were assessed when first seen, just before insertion of an intrathecal pump, and 9 months and 18 months later. Eighteen children waited around 9 months for a pump (group 1: nine males, nine females; mean age 9y 11mo [SD 3y 7mo], nine in Gross Motor Function Classification System [GMFCS] level IV, nine in level V). This baseline period was used as a control for comparison with the first and second 9-month periods after the pump for the remaining 20 children (group 2: 11 males, nine females; mean age 10y 2mo [SD 3y 1mo], nine in GMFCS level IV, 11 in level V). The main outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI); other assessments were of function, ease of care, quality of life, and costs of new equipment. RESULTS No significant change was found in the PEDI between group 1 while awaiting treatment and group 2 in the two periods afterwards, nor in the Lifestyle Assessment Questionnaire or the cost of new equipment. Significant changes were found in group 2 in the first 9 months according to the modified Ashworth score (difference between mean values for groups -1.7, standard error 0.58; p=0.008), Penn Spasm score (-1.3, 0.37; p=0.001), mean joint range of movement (8.3°, 2.8; p=0.005), and Caregiver Questionnaire (-19.7, 5.1; p=0.01), and in the second 9 months for the Modified Ashworth Scale score (-0.62, 0.12; p=0.001). INTERPRETATION ITB in children with severe spastic CP over the first 18 months improves their quality of life in terms of comfort and ease of care. It has less effect on function, participation in society, or the overall cost of new equipment.
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Affiliation(s)
- Richard E Morton
- Department of Paediatrics, Derbyshire Children's Hospital, Derby, and Queens Medical Centre, Nottingham, UK.
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Observational Analysis of Successful Reimplantation of Explanted Intrathecal Drug Delivery Systems: A Case Series. PM R 2011; 3:175-8. [DOI: 10.1016/j.pmrj.2010.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 08/11/2010] [Accepted: 08/12/2010] [Indexed: 11/23/2022]
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Affiliation(s)
- Yu-wei Hsieh
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-yi Wu
- Department of Occupational Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Keh-chung Lin
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, and Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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Sivan M. Interpreting Effect Size to Estimate Responsiveness of Outcome Measures. Stroke 2009; 40:e709; author reply e710-1. [DOI: 10.1161/strokeaha.109.566836] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Manoj Sivan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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31
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Abstract
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.
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Affiliation(s)
- Linda E Krach
- Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, 55455, USA.
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Francisco GE, Hu MM, Boake C, Ivanhoe CB. Efficacy of early use of intrathecal baclofen therapy for treating spastic hypertonia due to acquired brain injury. Brain Inj 2009; 19:359-64. [PMID: 16094783 DOI: 10.1080/02699050400003999] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of early (<1 year post-disease onset) use of intrathecal baclofen (ITB). DESIGN Consecutive case series of 14 individuals with spastic hypertonia due to trauma (5), anoxia (6) and stroke (3). MAIN OUTCOME MEASURES Modified Ashworth (MAS) and Disability Rating (DRS) scales. INTERVENTIONS ITB pump placement within 1 year of onset, after inadequate response to other previous treatment modalities. RESULTS At follow-up after ITB pump implantation (mean = 13.9 months; mean daily dose = 591.5 microg per day), mean MAS scores improved from baseline by 1.0 and 2.1 points in the upper and lower limbs, respectively. DRS scores did not change significantly. Functional gains included decreased pain and improved gait speed and motor skills. The only complication was spinal leak in one subject. CONCLUSIONS ITB therapy within 1 year of onset of acquired brain injury appears effective and safe in decreasing spastic hypertonia and does not appear to adversely affect recovery.
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Affiliation(s)
- G E Francisco
- Physical Medicine and Rehabilitation Alliance, Baylor College of Medicine and University of Texas Health Sciences Center, Houston, TX, USA.
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Bowden M, Stokic DS. Clinical and neurophysiologic assessment of strength and spasticity during intrathecal baclofen titration in incomplete spinal cord injury: single-subject design. J Spinal Cord Med 2009; 32:183-90. [PMID: 19569466 PMCID: PMC2678290 DOI: 10.1080/10790268.2009.11760770] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Spasticity after spinal cord injury (SCI) is commonly managed with oral and intrathecal baclofen (ITB), with less attention to the effects on voluntary motor control. Studies combining clinical and neurophysiologic assessments during dose optimization are rare. Study aims (a) systematically evaluate effects of varied doses of oral and ITB on clinical and neurophysiologic measures of strength and spasticity and (b) relate clinical and neurophysiologic findings. METHODS A 41-year-old man with an incomplete T11-ASIA D SCI was studied during ITB titration. Spasticity and strength in the lower extremities were assessed clinically and neurophysiologically at 5 different daily dosages of baclofen: (a) 80 mg oral, (b) 80 mg oral/50 microg ITB, (c) 80 mg oral/125 microg ITB, (d) 30 mg oral/125 microg ITB, and (e) 125 microg ITB only. RESULTS A dose-dependent change in the Ashworth score and lower limb motor score was observed during titration of oral and ITB. Whereas the Hoffman (H)-reflex was abolished after the introduction of ITB, the flexion withdrawal reflex approximated a dose-dependent pattern. Changes in the motor score and EMG during voluntary muscle activation were proportionally smaller than the corresponding changes in clinical and neurophysiologic measures of spasticity. Neurophysiologic assessment largely paralleled clinical findings. CONCLUSIONS This single-subject study shows that the control of spasticity can be achieved without detrimental effects on strength in incomplete SCI and suggests the need for including strength testing in comprehensive clinical assessment of spasticity. The study shows convergent validity between clinical and neurophysiologic assessments during ITB dose titration. Adding neurophysiologic assessment to clinical assessment may provide objectivity and sensitivity and facilitate decision-making during ITB titration.
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Affiliation(s)
- Mark Bowden
- 1Brain Rehabilitation Research Center, North Florida (South Georgia Veterans Health System, Gainesville, Florida)
| | - Dobrivoje S Stokic
- 2Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, Mississippi
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34
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Malfitano AM, Proto MC, Bifulco M. Cannabinoids in the management of spasticity associated with multiple sclerosis. Neuropsychiatr Dis Treat 2008; 4:847-53. [PMID: 19183777 PMCID: PMC2626929 DOI: 10.2147/ndt.s3208] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The endocannabinoid system and cannabinoid-based treatments have been involved in a wide number of diseases. In particular, several studies suggest that cannabinoids and endocannabinoids may have a key role in the pathogenesis and therapy of multiple sclerosis (MS). In this study we highlight the main findings reported in literature about the relevance of cannabinoid drugs in the management and treatment of MS. An increasing body of evidence suggests that cannabinoids have beneficial effects on the symptoms of MS, including spasticity and pain. In this report we focus on the effects of cannabinoids in the relief of spasticity describing the main findings in vivo, in the mouse experimental allergic encephalomyelitis model of MS. We report on the current treatments used to control MS symptoms and the most recent clinical studies based on cannabinoid treatments, although long-term studies are required to establish whether cannabinoids may have a role beyond symptom amelioration in MS.
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Affiliation(s)
- Anna Maria Malfitano
- Dipartimento di Scienze, Farmaceutiche, Università degli Studi di Salerno, di Salerno, 84084, Fisciano (Salerno) Italy
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35
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Kofler M, Quirbach E, Schauer R, Singer M, Saltuari L. Limitations of Intrathecal Baclofen for Spastic Hemiparesis Following Stroke. Neurorehabil Neural Repair 2008; 23:26-31. [DOI: 10.1177/1545968308317700] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. Intrathecal baclofen (ITB) has become the first choice in the management of deleterious spasticity that does not respond to oral and intramuscular medications following spinal cord injury, traumatic brain injury, and cerebral palsy. The usefulness of ITB in severe spastic hemiparesis following stroke is studied. Methods. A total of 8 patients underwent clinical and video assessment following ITB bolus application (n = 5) and during continuous infusion via a temporary catheter system (n = 3). Results. The mean daily dosage alleviating spasticity on the hemiparetic side—without affecting the nonparetic side—was 119 μg/day (range 50 to 360 μg/day). However, 6 patients experienced functional deterioration as ITB weakened their paretic side such that the antigravity pattern they used for ambulation was suppressed. In 2 patients, spasticity-associated pain and spasms subsided and they underwent implantation of a long-term drug delivery system. Conclusions. ITB may reduce spasticity in a dose-dependent manner irrespective of its origin. Although not primarily antinociceptive in humans, ITB may alleviate pain if arising from increased muscle tone. A functional benefit may result if ITB can uncover “subclinical” motor control that had been suppressed by spasticity. However, when a patient uses antigravity patterns for ambulation in the absence of more complex motor control, ITB may cause the loss of residual walking ability, which becomes a major limitation for patients with hemiplegic stroke.
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Affiliation(s)
- Markus Kofler
- Department of Neurology, Hospital Hochzirl, Zirl, Austria,
| | - Ellen Quirbach
- Department of Neurology, Hospital Hochzirl, Zirl, Austria
| | - Robert Schauer
- Department of Neurology, Hospital Hochzirl, Zirl, Austria
| | - Markus Singer
- Department of Neurology, Hospital Hochzirl, Zirl, Austria
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36
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Abstract
While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.
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37
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Repeated treatments with botulinum toxin type a produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients. Arch Phys Med Rehabil 2008; 89:799-806. [PMID: 18452724 DOI: 10.1016/j.apmr.2008.01.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 12/09/2007] [Accepted: 01/01/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the safety and evaluate the effects of repeated treatments with botulinum toxin type A (BTX-A) on functional disability, quality of life (QOL), and muscle tone of patients with upper-limb poststroke spasticity, as well as its effect on caregivers. DESIGN Multicenter, open-label, repeated-dose study. SETTING Thirty-five clinical sites in North America. PARTICIPANTS Patients (N=279) with upper-limb poststroke spasticity at 6 months or more poststroke. INTERVENTION Up to 5 intramuscular injections of BTX-A (200-400U) divided among the wrist, finger, thumb, and elbow flexors, with at least 200U in the wrist and finger flexors. Retreatment was permitted at 12 weeks or more after the last treatment. MAIN OUTCOME MEASURES Investigators rated disability using the Disability Assessment Scale and muscle tone using the Ashworth Scale. Each patient's health-related QOL was assessed by using the Stroke Adapted Sickness Impact Profile and the visual analog scale of the European Quality of Life-5 Dimensions questionnaires. RESULTS Patients treated with BTX-A reported improvements in muscle tone, disability, and ability to function that were statistically significant and clinically meaningful. Significant improvements were observed at week 30 and at subsequent time points in QOL in the overall group and the high-dose group. CONCLUSIONS Up to 5 treatments with BTX-A every 12 weeks for up to 56 weeks in patients with poststroke spasticity was well tolerated and significantly improved muscle tone, lessened disability, and improved patients' QOL. Further research is required to examine the effectiveness of repeated injections of BTX-A in patients with poststroke spasticity.
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38
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Elman LB, Houghton DJ, Wu GF, Hurtig HI, Markowitz CE, McCluskey L. Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis. J Palliat Med 2007; 10:433-57. [PMID: 17472516 DOI: 10.1089/jpm.2006.9978] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders. OBJECTIVES The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms. DESIGN The authors review current management and the supporting literature. CONCLUSIONS Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.
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Affiliation(s)
- Lauren B Elman
- ALS Association Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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39
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Rietman JS, Geertzen JHB. Efficacy of intrathecal baclofen delivery in the management of severe spasticity in upper motor neuron syndrome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:205-11. [PMID: 17691378 DOI: 10.1007/978-3-211-33079-1_28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- J S Rietman
- Roessingh Research and Development, Enschede, The Netherlands.
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40
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Strasser F, Driver LC, Burton AW. Update on adjuvant medications for chronic nonmalignant pain. Pain Pract 2007; 3:282-97. [PMID: 17166124 DOI: 10.1111/j.1530-7085.2003.03032.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Florian Strasser
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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41
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Lamotte D, Cantalloube S. Intérêt de la pompe à baclofène dans le traitement de la spasticité chez l'hémiplégique: à propos d'un cas. ACTA ACUST UNITED AC 2007; 50:165-9. [PMID: 17145092 DOI: 10.1016/j.annrmp.2006.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 11/06/2006] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- D Lamotte
- Service de médecine physique et de réadaptation, hôpital Reine-Hortense, boulevard Berthollet, 73100 Aix-les-Bains, France.
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42
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Dario A, Tomei G. Management of spasticity in multiple sclerosis by intrathecal baclofen. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:189-92. [PMID: 17691376 DOI: 10.1007/978-3-211-33079-1_26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Since its introduction, chronic intrathecal baclofen (ITB) infusion has been proved to improve spasticity, spasms and related pain. In the literature, the reported clinical improvement is evident in more than 85% of the patients suffering from spasticity and in more than 66% of the patients suffering from spasms. Usually, the evaluation of spasticity is carried out by the Asworth Scale although there is not yet general accordance on the validity of this scale. It is possible that some of the scales used to assess the implanted patients are not sensitive enough to detect changes in the quality of life or functional outcome. After the pump's implantation, the overall care seems to be rather simple for a devoted team. The side effects are usually temporary but they can worry the patients. The most dangerous side effects are baclofen overdose and withdrawal syndrome. These complications are totally avoidable by adopting an approach attentive to the details regarding the patient, the device, and the procedure.
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Affiliation(s)
- A Dario
- Neurosurgical Clinic, Insubria University, Varese, Italy.
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43
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Koulousakis A, Kuchta J. Intrathecal antispastic drug application with implantable pumps: results of a 10 year follow-up study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:181-4. [PMID: 17691374 DOI: 10.1007/978-3-211-33079-1_24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Since 1986, more than 300 patients received an intrathecal baclofen (ITB) pump for the treatment of severe spasticity. Chronic ITB administration is a safe and effective method, which significantly decreases pathologically exaggerated muscle tone and improves the quality of life in most patients. This therapy is indicated in severe spasticity of cerebral or spinal origin that is unresponsive to oral antispastic medications. It is also useful in patients who may experience intolerable side effects when they receive orally effective baclofen doses. The therapeutic dose required to treat spasticity of cerebral origin is about three times higher than in spasticity of spinal origin. In carefully selected patients who suffer from spasticity, pump implantation is a cost-effective treatment which improves their quality of life. In our series with a follow-up period of 10 years, the ITB dose remained constant and no development of tolerance was observed in most patients. Destructive procedures such as myelotomy are no longer performed in our department in order to treat spasticity.
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Affiliation(s)
- A Koulousakis
- Department of Neurosurgery, Cologne University, Cologne, Germany
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44
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Ivanhoe CB, Francisco GE, McGuire JR, Subramanian T, Grissom SP. Intrathecal Baclofen Management of Poststroke Spastic Hypertonia: Implications for Function and Quality of Life. Arch Phys Med Rehabil 2006; 87:1509-15. [PMID: 17084128 DOI: 10.1016/j.apmr.2006.08.323] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 06/09/2006] [Accepted: 08/09/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Cindy B Ivanhoe
- Brain Injury and Stroke Program, The Institute for Rehabilitation and Research, Houston, TX 77030, USA.
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45
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Henze T, Rieckmann P, Toyka KV. Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society. Eur Neurol 2006; 56:78-105. [PMID: 16966832 DOI: 10.1159/000095699] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 07/12/2006] [Indexed: 01/13/2023]
Abstract
Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.
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Affiliation(s)
- T Henze
- Reha-Zentrum Nittenau, Rehabilitationszentrum fur Neurologie, Nittenau, Germany.
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46
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Abstract
Intrathecal baclofen (ITB) is a recognized therapy for severe spasticity of both spinal and cerebral origin, with documented positive clinical outcomes for many patients with multiple sclerosis (MS). This article reviews some specific considerations concerning the use of ITB in the MS population, based on the author's 10 years of clinical experience. The unpredictable and progressive nature of the disease affects the identification of appropriate goals, the patient's decision-making process, and the evaluation of the response to the treatment over time. Patients with MS may be more sensitive to intrathecal baclofen than patients with other diagnoses, and may need a lower dose for both the screening test and maintenance therapy. Subtle cognitive changes may affect the patient's ability to understand the education needed for successful management of ITB. Some practical strategies are offered for the nurse involved in the care of these patients in each stage of the therapy.
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Affiliation(s)
- Barbara Ridley
- Spasticity Management Clinic, Alta Bates Summit Medical Center, Berkeley, CA 96704, USA.
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47
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Abstract
The management of childhood spasticity requires a multidisciplinary effort. With input from pediatricians, physical and occupational therapists, neurologists, orthotists, orthopedic surgeons, neurological surgeons, and other healthcare personnel, effective treatment for spasticity can be initiated and maintained that can lead to meaningful improvements in quality of life for vast numbers of children. Neurosurgical treatment of spasticity will continue to evolve and be refined as procedures and techniques are appropriately evaluated with reliable and validated outcome measures.
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Affiliation(s)
- Christopher E Mandigo
- Department of Neurological Surgery, The Children's Hospital of New York, Columbia University, New York, NY 10032, USA
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48
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Svendsen KB, Bach FW. Chapter 49 Pain in multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:731-745. [PMID: 18808871 DOI: 10.1016/s0072-9752(06)80053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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49
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Guillaume D, Van Havenbergh A, Vloeberghs M, Vidal J, Roeste G. A Clinical Study of Intrathecal Baclofen Using a Programmable Pump for Intractable Spasticity. Arch Phys Med Rehabil 2005; 86:2165-71. [PMID: 16271565 DOI: 10.1016/j.apmr.2005.05.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Revised: 04/15/2005] [Accepted: 05/25/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the impact of intrathecal baclofen (ITB) therapy on outcomes of functional independence, pain, subjective improvement, performance, and standard measures of spasticity. DESIGN A noncomparative, multicenter, prospective cohort trial of patients with implanted pumps followed up over a 12-month period for the assessment of spasticity, pain, and function. SETTING Twenty-four European centers of neurology or rehabilitation familiar with implantable pump technique participated. PARTICIPANTS Patients with intractable spasticity (N=138) who responded positively to a trial dose of baclofen (n=133) and who began ITB therapy (n=129) were enrolled. INTERVENTION Implantation of a Medtronic SynchroMed Infusion System with the administration of ITB therapy. MAIN OUTCOME MEASURES Ashworth Scale assessment, Penn Spasm Frequency Scale scores, pain assessment, FIM instrument scores or WeeFIM scores for children, Canadian Occupational Performance Measure (COPM), and subjective ratings of overall relief were the tools administered. RESULTS Muscle tone, spasm scores, and pain intensity reductions were observed. Overall FIM scores increased significantly in cognitive and motor function. COPM scores for both performance and satisfaction also improved significantly. Patients reported increased relief from pain and spasticity, supported by physician reports. Forty-three percent of patients reported adverse events, mostly related to patients' underlying conditions (20%), the device implant surgery (10%), or complications with the catheter (9%). CONCLUSIONS ITB therapy using a programmable pump is clinically effective and well tolerated, despite a seemingly high level of adverse events, in patients with intractable spasticity of spinal or cerebral origin and may offer improvements in pain relief and function.
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Affiliation(s)
- Daniel Guillaume
- Centre Neurologique et de Réadaptation Fonctionnelle, Fraiture-en-Condroz, Belgium
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Boviatsis EJ, Kouyialis AT, Korfias S, Sakas DE. Functional outcome of intrathecal baclofen administration for severe spasticity. Clin Neurol Neurosurg 2005; 107:289-95. [PMID: 15885386 DOI: 10.1016/j.clineuro.2004.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Revised: 08/23/2004] [Accepted: 09/02/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To estimate the functional benefit in patients with severe spasticity treated with intrathecal baclofen infusion through an implantable pump and to stress the need for functional assessment of these patients with a functional scale. PATIENTS AND METHODS Between 1999 and 2003, 22 patients with a long history of severe and disabling pharmaceutically intractable spasticity, underwent implantation of a pump for continuous intrathecal baclofen infusion. The patients were subdivided into two categories according to the aetiology of spasticity: 15 had Multiple Sclerosis and seven had suffered a Spinal Cord Injury at different levels (from C4 to T11). Clinical status was assessed with the Ashworth and Penn spasm scales. Functional benefits were evaluated with the Barthel index score and pain relief with a self-reported visual analogue pain scale. RESULTS Postoperatively, all patients presented improvement in spasticity, reduction of spasm frequency, significant improvement in functional status, enhancement of life comfort and reduction of pain. CONCLUSION Reduction of spasticity and spasms achieved with intrathecally delivered baclofen, leads to functional improvement and pain relief.
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Affiliation(s)
- Efstathios J Boviatsis
- Department of Neurosurgery, Evangelismos General Hospital, University of Athens Medical School, 61 Ipsilantou Street, Kolonaki, Athens 11521, Greece.
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