Intrathecal baclofen for severe spasticity: A meta-analysis

In order to evaluate the potential of intrathecal baclofen (IB) for treatment of severe spasticity, we meta-analyzed English-language literature and found that IB significantly reduces spasticity in most cases, reducing the mean Ashworth score from 3.9 to 1.6 (t-test: p ≤ .001) and the mean Penn spasm score from 3.2 to 0.6 (p < .001). No effectiveness differences by age or time since onset were evident; however, persons with cerebral palsy appear to experience less relief than do other diagnostic categories. Although 92% of all cases have a significant reduction in spasticity, a minority (8%) decide against implantation of a pump, and of those implanted, 8% discontinue treatment by one year, resulting in an overall 78% success rate. Dosage creep is about 15% per month, on average. Our conclusion is that IB is effective for treating spasticity but less so than previously claimed. Quantitative data to evaluate its effect on pain, comfort, and function are largely lacking. Further research on longer term effects, and complications, is necessary.     

Intrathecal baclofen for spasticity management in Rett syndrome

Intrathecal baclofen infusions have proven to be effective for management of spasticity during the last two decades. Efficacy of intrathecal baclofen for spasticity of spinal origin has been well established and has shown promise in treatment of spasticity that is not spinal in origin. Rett syndrome is a neurodevelopmental disorder primarily affecting girls and women. Manifested in the advanced stages of this syndrome is increased spasticity leading to functional decline. Presented is a case report of a 32-yr-old white woman with Rett syndrome, diagnosed before the age of 2 yr, and significant spasticity that was successfully managed with intrathecal baclofen. After placement of an intrathecal baclofen pump, the dose was increased slowly during 1 yr to 800 microg/day with good clinical response. There was observed a significant decrease in upper and lower limb Ashworth scores, from an average of 3-4 to 2-3, during this 1-yr period. The decrease in spasticity in this patient eventually led to improved range of motion, positioning, skin care, hygiene, and quality of life. Intrathecal baclofen is an effective option in managing severe spasticity from Rett syndrome.     

Intrathecal baclofen pump use for spasticity: a clinical survey

OBJECTIVE: To obtain information from continuous intrathecal baclofen infusion (CIBI) pump centers regarding specific clinical practices and experiences. METHODS: A total of 115 centers were surveyed by mail. RESULTS: Forty centers (35%) responded with information about 1,002 test doses and 936 pump placements. Patient diagnoses included cerebral palsy, spinal cord injury, traumatic brain injury, and others. The average test dose was 50 microg. A total of 87% of trials were successful. The most common test dose complications were nausea/vomiting (2.6%) and sedation (2.2%). Pump placement complications included cerebrospinal fluid (CSF) collection (3.3%), constipation (2.9%), headache (2.4%), and CSF leak (2.2%). The most common long-term complications were catheter kink or migration (4%) and infection (1.2%). Improved daily activities including easier diapering, dressing, transfers, orthotic wear and comfort, and sitting tolerance were reported in the majority (>90%) of patients. Mixed results were reported for oral motor function and head, bladder, and bowel control. CONCLUSIONS: CIBI is an effective treatment for severe spasticity, with dramatic quality-of-life improvements and a small number of significant complications. Long-term benefits and complications need to be monitored in this complex population.     

Intrathecal baclofen. Effects on nocturnal leg muscle spasticity.

Electromyographic activity was recorded from tibialis anterior during nocturnal polysomnography in six patients with severe spasticity of spinal origin. The patients had a baclofen reservoir system implanted subcutaneously into their lumbar subarachnoid space and were studied for two nights in a double-blind, placebo controlled, crossover design. Tibialis anterior electromyographic activity per hour of sleep was reduced on the night of baclofen infusion. In particular, less electromyographic activity occurred after arousal from sleep.     

Intrathecal baclofen overdose

Intrathecal baclofen administered by bolus or continuous infusion has been shown to be of benefit in the treatment of spinal spasticity. Reporting of complications has been limited, particularly in the emergency medicine literature. Reports have been primarily associated with clinical trials. We report a case of intrathecal baclofen overdose in a patient presenting to the emergency department with an altered level of consciousness and cardiorespiratory depression, who required mechanical ventilation, fluid resuscitation and intensive care admission. The literature is reviewed with respect to the action and effectiveness of intrathecal baclofen, use of the relevant implantable devices, suggested methods of management in overdose and the other reported complications from this treatment modality.     

Intrathecal administration of baclofen: the method of choice in the treatment of spasticity

This article presents principles of Intrathecal Baclofen Therapy. We are informed about general experiences of scientists in IBT. The author provides some basic data of baclofen pump sort, pre-implantation baclofen tests and surgical technique.     

Efficacy of intrathecal baclofen in the treatment of spasticity in stroke]

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.     

Intrathecal baclofen therapy for spastic hypertonia.

Intrathecal baclofen is perhaps the most effective treatment for significant spasticity regardless of the origin. For appropriately selected patients, it can provide qualitative and quantitative improvements in quality of life. This article discusses the practical aspects and patient selection, trial, implant, and ongoing management of patients with intrathecal baclofen pump therapy.     

Intrathecal baclofen withdrawal mimicking sepsis

Baclofen (Lioresal™) is a drug of choice to treat spasticity and is increasingly being administered intrathecally via an implantable pump in cases refractory to oral therapy. Emergency physicians will likely treat patients with baclofen withdrawal or overdose as this treatment becomes more widespread. The syndrome of baclofen withdrawal presents with altered mental status, fever, tachycardia, hypertension or hypotension, seizures, and rebound spasticity, and may be fatal if not treated appropriately. Baclofen withdrawal may mimic other diseases including sepsis, meningitis, autonomic dysreflexia, malignant hyperthermia, or neuroleptic malignant syndrome. Treatment consists of supportive care, reinstitution of baclofen, benzodiazepines, and diagnosis and eventual repair of intrathecal pump and catheter malfunction.     

The supraspinal anxiolytic effect of baclofen for spasticity reduction

Recent studies in the psychiatric literature indicate that baclofen has an anxiolytic action in certain psychopathologic conditions. Clinical observation has shown that manifestations of spasticity are increased in anxious individuals, implicating a supraspinal site of mediation for these responses. The purposes of this study were to determine if baclofen reduced anxiety in individuals with traumatic spinal cord lesions and whether that reduction was correlated with decreased spasticity from the baclofen. Five adult males with traumatic spinal cord injury were randomly assigned to the study protocol. A double-blind, repeated measures, multiple base-line, single-case research design was employed. The independent variable was dose of medication with the three levels being placebo, 40 mg/day of baclofen and 80 mg/day of baclofen, in four evenly divided doses. The dependent variable was the score obtained on the Beck Inventory-A anxiety scale (BIA). The subjects were administered the BIA twice per week for a nine-week period of time, during which they received the doses of medication as described. Quantitative measurements of spasticity were also taken at each session. Visual inspection analysis of the data showed that two subjects had no measurable anxiety of the BIA throughout the study. Three subjects had measurable anxiety on the BIA during the base-line/placebo phase. They showed a decreased level of their BIA scores with 40 mg/day of baclofen, and a further level reduction with 80 mg/day of baclofen. The reduction in BIA scores was statistically significant using the standard deviation band test in one of these subjects. These data indicate that BIA probably has an anxiolytic effect for individuals status post-traumatic spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intrathecal baclofen for generalized dystonia: a case report

Dystonia is an abnormal movement characterized by sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. Primary generalized dystonia usually evolves to a debilitating condition, often unresponsive to oral pharmacologic regimens or physical rehabilitation. We present the case of a patient with idiopathic adult-onset generalized dystonia who was recalcitrant to oral therapies. This patient was treated with intrathecal baclofen therapy and responded dramatically with improved functional abilities, resolution of chronic pain, and an improved rating on the dystonia scale.     

Intrathecal baclofen in hereditary spastic paraparesis.

Intrathecal baclofen has not been previously evaluated for the treatment of the disabling hypertonia associated with hereditary spastic paraparesis. Muscle tone and deep-tendon reflexes were evaluated in three patients with hereditary spastic paraparesis after a double-blind, cross-over bolus injection of intrathecal baclofen. Patients underwent placement of a subcutaneous pump for continuous infusion of intrathecal baclofen. Three months after implantation the muscle tone decreased 2.04 points (p less than .0001) and the reflex score decreased 2.25 points (p less than .001). Patients initially reported subjective weakness, but muscle testing revealed either an increase or no change in voluntary motor function. Baclofen doses of 60 to 264 micrograms per day were required for effective control of muscle tone and spasticity. Much of the disability in familial spastic paraparesis may be related to the loss of suprasegmental inhibition of spinal reflexes overwhelming the residual voluntary motor function.     

Intrathecal baclofen therapy over 10 years.

Intrathecal baclofen (ITB) therapy has evolved into a standard treatment for severe spasticity. After this therapy had been provided for 10 years, a retrospective chart review on 50 patients, representing a total 2,922 patient months of ITB service, was done. These patients suffered severe spasticity from a number of disease processes including multiple sclerosis, cerebral palsy, and brain injury. The average dosage for the total group was 463 micrograms per day (microg/day), and 32% used a simple infusion mode. Pump refills occurred every 3 months for 58% of the group. Three evolving trends in ITB therapy were identified from clinical trial to current management: (a) higher catheter tip placement, (b) use of more complex infusion modes, and (c) a decreased complication rate.     

Intrathecal baclofen withdrawal syndrome caused by low residual volume in the pump reservoir: a report of 2 cases

Intrathecal baclofen (ITB) is an effective treatment for spasticity caused by spinal or cerebral pathologies. Severe withdrawal symptoms can result, however, if ITB is abruptly withdrawn as a result of equipment malfunctions or human error. We describe 2 cases of severe ITB withdrawal syndrome. In the first case, the symptoms appeared 5 months after pump placement, when residual volume was 2.0 mL; in the second case, symptoms appeared 2 months after the replacement of a new pump, when residual volume was 0.9 mL. In both cases, there was no evidence of system malfunction or human error. The syndrome occurred from up to 72 hours before the scheduled refilling procedure, and the residual volume in the Medtronic SynchroMed EL pump reservoir was either at, or significantly lower than, the recommended 2 mL. These cases suggest that the SynchroMed EL pump reservoir should be refilled, to avoid potentially serious consequences, when the residual volume is not lower than 3 mL by programming the alarm to sound at a volume larger than the recommended 2 mL.     

Quantitative assessment of intrathecally administered baclofen in spasticity

OBJECTIVE: To quantitatively assess the antispastic effect of intrathecally administered baclofen on muscle stiffness in spastic patients. DESIGN: Case-control study. SETTING: Clinical laboratory in a university hospital of a city of more than 1,000,000 inhabitants. PARTICIPANTS: Eighteen healthy adult volunteers (9 men, 9 women) were recruited for establishing the normal values. Eleven spastic patients (8 men, 3 women) comprised the study group. MAIN OUTCOME MEASURES: The resistance to passive sinusoidal displacement of 5 degrees imposed to the ankle joint was measured at frequencies from 3 to 12 Hz. Torque and displacement signals were subjected to a Fourier analysis to isolate the elastic and viscous components of the total muscle stiffness. RESULTS: In comparison with the period before intrathecal injection, and with the control group, it was shown that at 4 hours after injection, stretch reflex activity was abolished and elastic and viscous muscle stiffness approached control values. The abnormal residual stiffness concerned only the elastic component due to chronic transformations of the spastic muscle and/or due to changes in joints and periarticular connective tissue. This antispastic effect was completely reversed 36 hours after injection. CONCLUSION: The present study shows that the antispastic effect of intrathecally administered baclofen in spastic patients can be quantitatively assessed by a sensitive method allowing measurement of elastic and viscous components of muscle stiffness.     

Acitretin-associated thrombotic stroke

OBJECTIVE: To report a case of thrombotic stroke. The etiology was difficult to identify, but was finally ascribed to psoriatic treatment with acitretin. CASE SUMMARY: Treatment with acitretin was prescribed for a 52-year-old white woman for long-standing psoriasis. Thirty-four days later, she developed nausea, vomiting, vertigo, and headaches, followed by left lateropulsion, which impeded standing and lying. Both neurologic examination and magnetic nuclear imaging indicated a rectangular infarct in the vermis cerebelli and a small bulbar infarct. Time-of-flight magnetic resonance angiography confirmed the presence of a thrombus at the beginning of the left vertebral artery. After heparin-based treatment and physiotherapy, the evolution was favorable. DISCUSSION: Etiology identification of the stroke included cardiogenic pathology and coagulopathy, but acitretin treatment was considered the likeliest explanation. On review of the literature, this seems to be the first case of a thrombotic event associated with acitretin. CONCLUSIONS: Acitretin should be considered as a possible cause of thrombotic stroke; this possibility should be kept in mind when patients taking acitretin develop an unexplained thrombotic event.     

Intrathecal baclofen therapy and the child with cerebral palsy

Children with cerebral palsy have tight, spastic muscles that often interfere with function, care, and, ultimately, quality of life. Until recently, treatment usually focused on the effects of the spasticity rather than the spasticity itself. Intrathecal Baclofen Therapy (ITB) administers a muscle-relaxing agent directly into the intrathecal space; thereby decreasing the amount of spasticity the child exhibits. This article discusses cerebral palsy and a new treatment for spasticity, ITB, and the development of an ITB program.