Intrathecal Baclofen for Spastic Hypertonia From Stroke Editorial Comment (original) (raw)
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Intrathecal Baclofen for Spastic Hypertonia From Stroke
Background and Purpose—We sought to determine whether continuous intrathecal delivery of baclofen can effectively decrease spastic hypertonia due to stroke. Methods—Stroke patients with .6 months of intractable spasticity were screened via a randomized, double-blind, placebo-controlled crossover design of either intrathecal normal saline or 50 mg baclofen. Those who dropped an average of 2 points in either their affected lower extremity side Ashworth or Penn spasm frequency scores were then offered computer-controlled pump implantation for continuous ITB and followed prospectively for up to 12 months. Results—In 21 stroke patients 6 hours after the active drug bolus, the average ( 6SD) lower extremity Ashworth score on the affected extremities decreased from 3.361.2 to 1.460.7 (P,0.0001), spasm score from 1.261.2 to 0.160.3 (P50.0224), and reflex score from 2.161.2 to 0.160.5 (P,0.0001). The average upper extremity Ashworth score on the affected extremities decreased from 2.861.1 to...
Archives of Physical Medicine and Rehabilitation, 1996
Meythaler JM, DeVivo MJ, Hadley M. Prospective study on the use of bolus intrathecal baclofen for spastic hypertonia due to acquired brain injury. Arch Phys Med Rehabil 1996;77:461-6. Objective: To determine if the intrathecal delivery of baclofen will decrease spastic hypertonia caused by brain injury. Patients: Eleven patients more than 1 year after their brain injury with disabling lower extremity spastic hypertonia. Setting: University tertiary care outpatient rehabilitation clinic. Design: Patients were a consecutive sample randomized in a double blind, placebo-controlled crossover study. Interventions: Bolus intrathecal injection of either normal saline or 50 #g baclofen. Main Outcomes Measures: Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Changes over time were assessed via Friedman's test. Differences between the placebo and active drug at any given time were assessed via Wilcoxon signed-rank. Results: Four hours after injection with the active drug (maximum effect) the average LE Ashworth score decreased from 4.2-0.8 (SD) to 2.2 + 0.6 (p = .0033), spasm score from 3.1 ___ 1.0 to 1.0 _ 0.7 (p = .0032), and reflex score from 3.3 ___ 0.5 to 1.0 __. 1.3 (p = .0033). The average UE Ashworth score decreased from 3.3 + 1.3 to 1.9 ___ 0.8 (p = .0033), spasm score from 1.8 _+ 1.3 to 0.6 __. 1.0 (p = .007), and reflex score from 2.7-0.5 to 1.7 ___ 0.6 (p = .0111). No trend was observed over time with placebo administration. There were significant reductions in the average for LE Ashworth (p < .0001), spasm (p < .0001), and reflex (p < .0001) scores and for LIE Ashworth (p < .0001) and spasm (p < .0004) scores observed over 4 hours (maximum effect) with active drug administration. No significant differences were noted between the active drug and placebo groups before administration in LE and UE Ashworth, spasm, or reflex scores. There were significant differences between the active drug and placebo groups at 4 hours after administration for LE and LIE Ashworth, spasm, and reflex scores (p-< .0272).
Topics in Stroke Rehabilitation, 2006
Intrathecal baclofen (ITB) therapy has been increasingly employed for the management of poststroke spastic hypertonia, a complication that can lead to deformity, discomfort, and exacerbation of motor impairments. Because its use in stroke is not as established as other indications, ITB therapy has not been subjected to rigorous investigation. There is limited evidence to guide clinicians regarding application of this therapy in this patient population. This article aims to review the available scientific literature and the opinion of several experts on the topic. It will also describe the recommendations of these experts with regard to addressing common clinical situations that may influence treatment decisions in the stroke population.
Clinical Neurophysiology, 2006
Objective: To determine the relationship between the H-reflex (H/M ratio) and continuous intrathecal baclofen (CITB) dose after pump implantation for control of spastic hypertonia. Methods: Soleus H-reflexes were serially recorded in 34 subjects (19 men, mean age 32 years, mean follow-up 1.7 years) during simple continuous mode of CITB delivery. Different fitting methods were explored to determine which function best described changes in H/M ratio with increasing CITB dose. We then calculated effective CITB doses yielding H/M ratios equal to 75, 50, and 25% (ED 75 , ED 50 , ED 25 ) of the baseline recorded before the implant in 22 subjects. Results: We found a significant dose-response relationship between the soleus H/M ratio and CITB dose. A two-decay exponential function was the best fit on each side for pooled data, but a general linear model when controlling for subject. The mean ED 75 , ED 50 , ED 25 were 30, 70, and 110 mcg/day. Logistical regression predicted with high probability that the H/M ratio should be less than 30% at CITB doses above 150 mcg/day. Conclusions: H/M ratio is strongly dependent on CITB dose. It sharply decreases up to 150 mcg/day of CITB followed by a plateau. Significance: Establishing the relationship between the H/M ratio and CITB dose may be useful for dose titration and early identification of an ITB system malfunction.
Archives of Physical Medicine and Rehabilitation, 1999
To determine if the long-term use of continuously infused intrathecal baclofen (ITB) over a 1-year period will control spastic-dystonic hypertonia in patients with traumatic brain injury (TBI). Tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital. Persons with TBI and intractable spasticity and dystonia for more than 6 months' duration recruited in a consecutive manner. TBI patients were admitted to the study after screening via a bolus injection of either intrathecal normal saline or 50 microg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Patients whose LE Ashworth scores decreased an average of 2 points were then offered implantation of a computer-controlled pump for continuous ITB. Changes over time were assessed statistically via Friedman's analysis for ordinal data and ANOVA for linear data. Differences between set points in time were also assessed via Wilcoxon signed rank. Seventeen patients (average age 29+/-11 yrs) with spasticity and/or dystonia treated over 1 year via a computer-controllable intrathecal delivery system for the delivery of ITB. After 1 year of continuous ITB treatment the average LE Ashworth score decreased from 3.5+/-1.3 (SD) to 1.7+/-0.9 (p < .0001), spasm score from 1.8+/-1.3 to 0.2+/-0.5 (p< .0001), and reflex score from 2.5+/-1.1 to 0.1+/-0.3 (p < .0001). The average UE Ashworth score decreased from 2.9+/-1.5 to 1.6+/-1.0 (p < .0001), spasm score from 1.2+/-1.5 to 0.2+/-0.6 (p < 0.0001), and reflex score from 2.2+/-0.5 to 1.0+/-0.8 (p < .0001). The average ITB dose required to attain these effects at 1 year was 302 microg continuously infused per day. Continuous intrathecal infusion of baclofen is capable of maintaining a reduction in spasticity and dystonia in both the upper and lower extremities of TBI patients.
Journal of Neurosurgery, 1997
✓ Twelve consecutive patients with severe spasticity and hypertonia following acquired brain injury were treated with continuous intrathecal infusion of baclofen via an implanted, programmable infusion pump—catheter system for a minimum of 3 months. In every case intrathecal baclofen therapy resulted in a statistically significant reduction in upper- and lower-extremity tone, spasm frequency, and reflexes, contributing to improved functional abilities. There were no untoward side effects or complications associated with treatment. This preliminary assessment indicates that intrathecal administration of baclofen is effective in treating the disabling spasticity caused by acquired brain injury in selected patients.