鞘内注射巴氯酚在治疗脑性瘫痪儿童痉挛中的应用

鞘内注射巴氯酚由于作用持久,全身副作用轻等优点被应用于治疗脑瘫儿童痉挛。介绍了鞘内注射巴氯酚的原理及其实施方法。综述了鞘内注射巴氯酚治疗脑瘫儿童上肢或下肢痉挛的有效性和安全性的文献(含非对照性研究和对照性研究),鞘内注射巴氯酚是一种有效的缓解脑瘫痉挛的疗法。     

Spasticity in children with cerebral palsy: a retrospective review of the effects of intrathecal baclofen

The administration of baclofen by intrathecal pump is a new technique used to reduce spasticity for individuals with upper motor neuron system injuries. Children with cerebral palsy often have difficulty in mobility because of this form of spasticity. The purpose of this study was to assess the functional outcomes of intrathecal baclofen pump therapy with spasticity in children with cerebral palsy. A retrospective review of medical records for pediatric cerebral palsy patients receiving intrathecal baclofen for intractable spasticity was performed. Of 23 sequential medical records meeting requirements for inclusion in the study, 17 subjects had sufficient recorded data to be included in the study. Data from the medical records included Ashworth scores, therapy complications, and changes in mobility and independence. Although no significant changes in the upper extremities with intrathecal baclofen occurred at one and three months, the trial bolus showed statistically significant changes in mean Ashworth scores. The pre- and posttrial bolus Ashworth scores for the lower extremities showed statistically significant decreases in the posttrial scores and at one and three months when compared with the pretrial scores (p < .001). Complications were resolved with conservative management without long-term sequelae. No infections, respiratory depressions, or deaths occurred as a result of intrathecal baclofen therapy in this study. Although intrathecal baclofen had a significant effect in reducing lower extremity spasticity in children with cerebral palsy, further prospective studies are needed to determine the effects of intrathecal baclofen on such indicators as activities of daily living.     

Mechanical measurements of the effects of intrathecal baclofen dosage adjustments in cerebral palsy: a pilot study

OBJECTIVE: The purpose of this pilot study was to determine the feasibility of using mechanical measures of stretch reflexes to monitor spasticity after intrathecal baclofen dosage changes. DESIGN: Mechanical measures were made in studying six participants with cerebral palsy who were undergoing treatment for spasticity using intrathecal baclofen therapy. Mechanical measurements of stretch reflexes were made before and after pump implant in four of the six participants and after dosage changes in all participants, for a period of up to 2 yrs. The measurements comprised electromyograms and resistive torque responses to movement of the ankle, imposed with an isokinetic dynamometer. For each test session, random movements were applied to the ankle at each of four to seven speeds, repeated three or five times. RESULTS: Stretch reflex excitability decreased in three of four participants after initiation of intrathecal baclofen therapy and decreased with increasing dosages in three of the six participants. Broken catheters coincided with heightened mechanical measures in two cases. CONCLUSION: Mechanical measures of stretch reflexes change after intrathecal baclofen dosage adjustments, reflecting the clinical course of intrathecal baclofen therapy.     

The contribution of tone to resting energy expenditure in children with moderate to severe cerebral palsy: Evaluation utilizing intrathecal baclofen injection

The extent to which high muscle tone contributes to the caloric needs of children with cerebral palsy (CP) is debated. Understanding its contribution is important in predicting calorie needs in this population which frequently experiences under nutrition. Intrathecal baclofen is an innovative therapy now used for treatment of excessive tone. We prospectively studied the changes in resting energy expenditure (REE) observed in 12 children with CP undergoing intrathecal baclofen injection. REE was measured in the fasting state before intrathecal injection of 50 micrograms of baclofen. Patients remained fasting and REE measures were repeated four hours later. Tone changes were assessed using the Modified Ashworth Scale at the same time points. One child was excluded from study because he became increasingly agitated over the observation period and one child demonstrated no tone reduction after the baclofen injection. In the remaining 10 patients, the average REE prior to injection was 101 ± 17% of predicted and decreased to 84 ± 24% of predicted after injection (p<0.004). This study suggests that tone contributes substantially to the caloric needs of children with CP and must be carefully considered when providing nutritional recommendations.     

Improvement in walking speed in poststroke spastic hemiplegia after intrathecal baclofen therapy: a preliminary study

OBJECTIVE: To explore whether intrathecal baclofen (ITB) therapy improves ambulation in stroke survivors. DESIGN: Case series. SETTING: Tertiary care center. PARTICIPANTS: Ten adults with poststroke hemiparesis who were ambulatory at the time of pump implantation. INTERVENTIONS: Implantation of ITB pump after inadequate control of spasticity with other interventions. Time from stroke onset to implantation averaged 28.6 months (range, 9-55mo). MAIN OUTCOME MEASURES: Customary walking speed was measured from the time required to walk 50ft (15m) at a self-selected pace. Evaluators rated spastic hypertonia and functional mobility. RESULTS: Statistically significant improvements occurred in walking speed, functional mobility ratings, and spasticity (P<.05) at a follow-up interval that averaged 8.9 months. Mean walking speed over 50ft improved from 36.6 to 52cm/s. Mean Modified Ashworth Scale scores in the muscles of the affected lower limb improved from 2.0 to 0.4. Normal muscle strength (5/5) was preserved in the unaffected limbs. CONCLUSIONS: This preliminary study suggests that ITB therapy, in combination with physical therapy, may improve walking speed and functional mobility in ambulatory individuals with poststroke spastic hemiplegia.     

Motor function improvement following intrathecal baclofen pump placement in a patient with locked-in syndrome

We describe a patient with locked-in syndrome who had minimal volitional motor function and severe spasticity in all four extremities. The patient showed a significant improvement in volitional motor function following intrathecal baclofen pump therapy to control spasticity. This case study suggests that intrathecal baclofen pump therapy might improve motor function in select patients with locked-in syndrome.     

Weight gain in children with hypertonia of cerebral origin receiving intrathecal baclofen therapy

OBJECTIVE: To identify the pattern of weight change in children receiving intrathecal baclofen (ITB) therapy. DESIGN: A retrospective medical chart review was conducted to identify weight status before and after ITB pump implantation. SETTING: Tertiary care children's hospital and academic medical center. PARTICIPANTS: All children and adolescents with hypertonia of cerebral origin who were younger than 19 years of age at the time of pump placement and followed in our pediatric baclofen pump program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A linear mixed model was used to examine the rate of change in weight (weight-gain velocity) before and after surgery. Weight change was adjusted for age, sex, functional level determined by the Gross Motor Functional Classification System, tube feeding, dystonia, and other comorbidities. RESULTS: The average weight-gain velocity was 2.32 kg/y presurgery and 2.93 kg/y postsurgery, adjusted for potential confounders. The 0.61 kg/y increase in weight-gain velocity attained statistical significance (P = .028). CONCLUSIONS: Although excessive weight gain is not a common problem in children with cerebral origin spasticity, increased weight-gain velocity is prevalent in children receiving ITB therapy. Health care providers may anticipate a welcome weight gain in the underweight child. This consequence should be considered when managing children receiving ITB therapy, and health care providers must appropriately intervene to prevent excessive weight gain. Further studies exploring the reasons for the increased weight-gain velocity are warranted.     

Intrathecal baclofen therapy in children with cerebral palsy: efficacy and complications

OBJECTIVES: To describe the efficacy of intrathecal baclofen (ITB) therapy in the management of spasticity in young children with cerebral palsy (CP) and to identify risk factors for complications. DESIGN: Consecutive case series of 25 implanted ITB delivery systems during a 48-month period. SETTING: Pediatric specialty hospital and outpatient department. PARTICIPANTS: Twenty-three children (age range, 4.5-17.4y) with CP (spastic diplegia in 22%; spastic quadriplegia in 61%; mixed-type diplegia in 4%; mixed-type quadriplegia in 13%). INTERVENTION: Intrathecal baclofen therapy in children with cerebral palsy. MAIN OUTCOME MEASURES: Ashworth Scale scores before treatment and at 6 and 12 months after ITB therapy; frequency and nature of complications; and relation between patient characteristics and outcomes. RESULTS: Average Ashworth scores +/- standard deviation decreased from 3.26+/-.73 to 2.34+/-.83 (P相似文献   

Upper extremity casting: adjunct treatment for a child with cerebral palsy hemiplegia

A common upper extremity deformity with hemiplegia is pronation contracture of the forearm in association with flexion contracture of the elbow. Early management of the child with hemiplegic cerebral palsy is critical in optimizing overall function. The use of inhibitory upper extremity casting can enhance function and improve arm-hand position. The present paper describes the evaluation process before casting, the goals of each phase of the casting program, and the follow-up.     

Use of intrathecal baclofen in a child with spastic paraparesis related to human immunodeficiency virus infection: A case report

This case report describes a 2-year treatment course of a 6-year-old with spastic paraparesis due to human immunodeficiency virus (HIV) encephalopathy. She continued to develop worsening musculoskeletal problems and a decline in mobility despite aggressive antispasticity interventions. In addition to meeting the usual clinical criteria for treatment with continuous intrathecal baclofen (ITB), she was believed to be an appropriate candidate for ITB because of adequate treatment of her HIV infection and associated overall low risk of mortality. For over 12 months, she has been successfully treated with ITB and has not developed any complications related to her HIV infection. To my knowledge, this is the first reported successful treatment of spasticity with ITB in a patient with stable HIV infection.     

Intrathecal baclofen in cerebral palsy: A decade of treatment outcomes

Continuous intrathecal baclofen (CITB) is considered a standard treatment for spasticity in patients with cerebral palsy (CP). This review summarizes the recent literature and assesses the evidence for the efficacy of ITB for spasticity and its related sequelae in patients with CP. The literature was searched using electronic databases and reference lists from March 2000 through April 2007. Studies included report treatment effects of ITB in patients with CP. The outcomes reported in the 29 studies identified are classified using the International Classification of Functioning, Disability and Health model. The studies are graded for their level and, when appropriate, quality of evidence. The majority of the studies are case series which receive a Level IV grade of evidence. One study provides Level II evidence for the reduction of spasticity after administration of a bolus test dose of ITB as documented by changes in neurophysiologic reflexes. Longer term studies support the effectiveness of CITB for maintenance of muscle tone reduction as documented by clinical scales. Multiple studies suggest a linkage of CITB with improvements in function, ease of care, and quality of life. The evidence for improvements in dystonia and musculoskeletal problems is equivocal. Limitations of the research in this area and recommendations for improving its quality are discussed.     

Intrathecal baclofen therapy improves functional intelligibility of speech in cerebral palsy

OBJECTIVE: To assess the effect of intrathecal baclofen on spastic dysarthia in cerebral palsy. DESIGN: Single case study. METHODS: Functional outcome measures, including the Assessment of Intelligibility of Dysarthric Speech, were performed before and after a trial of intrathecal baclofen in an adult patient with spastic dysarthria due to cerebral palsy. The patient proceeded to intrathecal baclofen pump implantation and was reassessed after six months of continuous intrathecal baclofen therapy. RESULTS: Improvement in function including speech intelligibility was seen following the intrathecal baclofen trial. The improvement was sustained at six months post pump implantation. CONCLUSIONS: Intrathecal baclofen improved functional intelligibility of speech in a carefully selected subject. The Assessment of Intelligibility of Dysarthric Speech was found to be a useful quantitative tool to assess the effect of intrathecal baclofen on spastic dysarthria.     

Improvement of sleep apnea in a patient with cerebral palsy.

Intrathecal baclofen (ITB) can reduce spasticity in adults and children with cerebral palsy. Benefits of ITB therapy include improved Ashworth scores, activities of daily living, and mobility. The impact of ITB therapy on sleep apnea in patients with cerebral palsy has not been reported. This case report describes a 29-yr-old female with mixed spastic athetoid quadriparetic cerebral palsy with dystonia, gross motor function IV, who had sleep apnea, requiring nightly continuous positive airway pressure. She received ITB with the goal to improve her wheelchair positioning and decrease her excessive movements. After the initiation of the ITB, reduction of her spasticity and dystonia was noted, as well as improvement of her sleep apnea. This case suggests that ITB therapy may improve respiratory function through reduction of respiratory muscle spasticity.     

Use of a faecal shunt system in an orthopaedic surgery unit in a patient with a necrotizing fasciitis of the perineal region

Necrotizing fasciitis is a severe infection of the subcutaneous tissue, with a higher mortality if treatment is not adequate. Nursing care can be fundamental in obtaining a good outcome of the healing process. We present a case of an 80 year-old diabetic patient admitted to our orthopaedic surgery unit as consequence of a screw displacement in her hip. She was operated on and had to be immobilized during the postsurgical period. Measures were applied to prevent bed sores in the sacral region. Despite these measures the patient developed a pressure sore that became infected, progressing to a necrotizing fasciitis of perineal and bulbar region, which required surgical curettage. Due to contact and exposure to faecal material it was decided to use a faecal shunt system. The number and difficulty of the wound treatments decreased using this system, which had significant advantages for the patient and nurses and for a favourable outcome of the wound. Employing faecal shunt systems could be useful when they are used earlier in patients immobilized due to orthopaedic surgery, with bowel movement changes and bed sore wounds.     

Successful multidrug treatment of a pediatric patient with severe Churg-Strauss syndrome refractory to prednisolone

Churg-Strauss syndrome (CSS), which is characterized by systemic small-vessel vasculitis of unknown etiology, is associated with a history of asthma. Although reports of CSS occurring in children are limited, effective treatment of pediatric patients with severe CSS remains challenging. A 10-year-old Japanese boy with a 6-month history of asthma treated with a leukotriene modifier, pranlukast, developed high fever, pleural infiltration, and pericarditis that were associated with marked hypereosinophilia (10,350 eosinophils/μl). Owing to his persistent high fever, mononeuritis multiplex, and severe abdominal pain that was refractory to prednisolone, his general condition progressively deteriorated thereafter. Although intravenous high-dose immunoglobulin administration was transiently effective for mononeuritis multiplex, the recurrent high fever and severe abdominal pain remained refractory. An endoscopic study revealed ulcerative lesions of the total colon. In this context, we treated the patient with an aggressive multidrug immunosuppressive regimen consisting of a high-dose methylprednisolone pulse plus short-course intravenous cyclophosphamide pulse therapy, followed by oral tacrolimus combined with prednisolone. After the rescue multidrug treatment, his severe clinical signs dramatically subsided within a short time, and the concomitantly administered prednisolone was successfully tapered without flare. At present, 12 months after the presentation, he is free from CSS signs or therapy-related toxicity except for an occasional mild asthma attack. Although further close observation should be needed to draw a long-term outcome in this patient, we believe that aggressive multidrug immunosuppressive treatment should be considered as an alternative rescue treatment in selected patients with severe CSS, even with pediatric-onset disease, that is refractory to prednisolone.     

The effect of intravenous verapamil on cerebral hemodynamics in a migraine patient with hemiplegia

OBJECTIVE: To describe the use of intravenous verapamil in a migraine patient with hemiplegia to reverse the symptomatology and hemodynamics of the middle cerebral artery as determined by transcranial Doppler. CASE SUMMARY: A 31-year-old white woman was admitted with an acute exacerbation of migraine with hemiplegia. A transcranial Doppler showed an increased flow velocity through the middle cerebral artery consistent with a migrainous process. The patient was treated with verapamil 5 mg iv and the hemiplegia gradually resolved. A transcranial Doppler indicated that the flow velocity through the middle cerebral artery was decreased after verapamil administration, indicating reversal of the vasospasm. DISCUSSION: Transcranial Doppler has not been previously used to determine the effect of intravenous verapamil on the migrainous process. Intravenous verapamil reversed the altered hemodynamics of the middle cerebral artery as determined by transcranial Doppler. This finding correlated with the gradual resolution of hemiplegia. Whether both subjective and objective findings in this patient can be attributed to the reversal of the cerebral artery hemodynamics is not known. CONCLUSIONS: Intravenous verapamil appears to reverse the vasospasm that may be associated with a migrainous process. Whether this effect is solely responsible for clinical improvement is not known. Verapamil may be a consideration for the treatment of intractable migraine, especially when there is evidence of spasm of the major cerebral arteries.