Poststroke Spasticity Management

The present national survey seeking to identify unmet needs in the management of spasticity with botulinum toxin type A focused on the use of OnabotulinumoxinA, since this is the brand with the widest range of licensed indications in Italy. Physicians from twenty-four Italian neurorehabilitation units compiled a questionnaire about "real-life" post-stroke spasticity management. OnabotulinumtoxinA was reported to be used in the following average doses: upper limb 316.7 ± 79.1 units; lower limb 327.8 ± 152.3; upper and lower limb 543.7 ± 123.7 units. Of the physicians surveyed, 37.5% felt that increasing the frequency of OnabotulinumtoxinA injection would improve its efficacy; 70.8% use electrical stimulation/electromyography guidance (one fourth of injections with no instrumental guidance). Instrumental evaluation was used by 41.7% of the physicians. The participants expressed the view that early identification of post-stroke spasticity would be facilitated by the availability of a post-stroke checklist, and that this should be used by physiotherapists (91.7%), physiatrists (58.3%), family doctors (50%), stroke unit physicians (25%), patients and caregivers (79.2%). According to our findings, the management of poststroke spasticity has several unmet needs that, were they addressed, might improve these patients' clinical outcomes and quality of life. These needs concern patient follow-up, where a clearly defined pathway is lacking; furthermore, there is a need to use maximum doses per treatment and to ensure early intervention on post-stroke spasticity.

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

<h3>Objective:</h3> To assess resting-state functional connectivity (rsFC) of the ipsilesional superior parietal lobule (SPL) and intraparietal sulcus (IPS) using functional magnetic resonance imaging (fMRI) in chronic stroke patients with hemiparesis both with and without post-stroke spasticity (PSS) and to explore the relationship between SPL/IPS resting-state functional connectivity (rsFC) and PSS severity. <h3>Background:</h3> Posts-stroke spasticity hampers effective rehabilitation of the paretic arm and lowers the quality of life. Effective PSS treatment with botulinum neurotoxin (BoNT) is associated with transient decrease in task-related fMRI activation of the ipsilesional SPL and IPS. We hypothesized that this would be reflected in changes in rsFC of the SPL/IPS. <h3>Design/Methods:</h3> Fourteen chronic stroke patients with upper limb weakness and PSS (the PSS group) and 8 patients with comparable weakness but no PSS (the control group) underwent clinical and spasticity evaluation and 3 fMRI examinations, at baseline (W0) and 4 and 11 weeks after BoNT (W4 and W11, respectively). Seed-based rsFC of the atlas-based SPL and IPS was evaluated using a group×time interaction analysis and the change in rsFC of SPL/IPS was correlated with change in PSS (modified Ashworth scale), integrity of the ipsilesional somatosensory afferent pathway (evoked potential N20 latency), and age. <h3>Results:</h3> In the PSS group, transient improvement in PSS was associated with increase in rsFC between the ipsilesional IPS and the contralesional SPL at W4. The interhemispheric connectivity was negatively correlated with PSS severity at baseline and with PSS improvement at W4. These changes in the posterior parietal interhemispheric rsFC suggest that previously observed task-related changes in SPL/IPS were independent of actual task performance. <h3>Conclusions:</h3> We propose adaptation of the internal forward model as the possible underlying mechanism and discuss its potential association with increased limb use or improved motor performance, as well as its potential contribution to the clinical effects of BoNT. <b>Disclosure:</b> The institution of Prof. Hlustik has received research support from Czech Health Research Council (AZV CR). Dr. Hok has nothing to disclose. Tomas Veverka has nothing to disclose. Markéta Trnecková has nothing to disclose. Pavel Otruba has nothing to disclose. Jana Zapletalova has nothing to disclose. Zbynek Tudos has nothing to disclose. Prof. Lotze has received publishing royalties from a publication relating to health care. Dr. Kanovsky has nothing to disclose.

Intrathecal baclofen (ITB) therapy, a viable alternative for unsuitable candidates of conventional spasticity medications, is a preferred method of administration over the oral route. Owing to its enhanced bioavailability, ITB ensures a more effective delivery at the target site. There is a lack of conclusive evidence regarding the use of ITB treatment in managing ambulatory patients with spastic dystonia. Before ITB pump implantation, patients commonly undergo an ITB bolus injection trial to rule out potential adverse reactions and verify the therapeutic effects on hypertonic issues. In this report, we highlight a case of spastic dystonia, particularly focusing on an ambulatory patient who demonstrated significant improvement in both the modified Ashworth scale (MAS) score and gait pattern following the ITB injection trial. This case report outlines the medical history of a 67-year-old male diagnosed with left-side hemiplegia and spastic dystonia, resulting from his second episode of intracranial hemorrhage in the right thalamus. An ITB injection trial was initiated because the patient was not suitable for continued botulinum toxin injections and oral medications. This was due to the persistent occurrence of spastic dystonia in both the upper and lower extremities. The patient underwent a four-day ITB injection trial with progressively increasing doses, resulting in improved MAS scores and gait parameters, including cadence, step length, step time, stride length, and stride time were increased. Particularly, kinematic gait analysis demonstrates a substantial improvement of increased knee flexion in the swing phase in stiff knee gait pattern. These findings indicated a gradual reduction in spasticity-related symptoms, signifying the positive effect of the ITB injection trial. The patient eventually received an ITB pump implantation. In this post-stroke patient with spastic dystonia, ITB therapy has demonstrated effective and substantial management of spasticity, along with improvement in gait patterns.

Objective: Spinal cord stimulation (SCS) is one of the widely used procedures for the treatment of complex regional pain syndrome (CRPS). However, complete pain relief is rarely achieved, and the SCS effect diminishes over time. Recently intrathecal baclofen (ITB) therapy is reported to be a modality for treating fixed dystonia related to CRPS. Other reports have suggested that ITB therapy can enhance the effect of SCS in patients with neuropathic pain. We report the effectiveness of combined SCS and ITB therapy, focusing on the role of ITB therapy as an adjunctive therapy for controlling symptoms of advanced CRPS. Methods: Five affected extremities of 4 patients with CRPS (2 male; mean age, 32.5 years) refractory to conservative treatment were evaluated retrospectively. Three patients underwent SCS implantation first, with ITB pumps being implanted a few years later. Bolus ITB injection was administered under temporary percutaneous SCS in 1 patient. Pain intensity was evaluated using the visual analogue scale (VAS) before and after ITB administration. Results: Pain relief of more than 50% was observed in the upper extremity of 1 patient and one of more than 30% was observed in 2 patients. The mean pain reduction rate in all 4 patients was 28.9% before and 43.8% after treatment. All patients, including those without any improvements in VAS score, showed decreased postural abnormalities after combined SCS and ITB therapy. Improvement in postural abnormalities, such as fixed dystonia or paroxysmal tremor-like movements, resulted in overall pain relief by reducing pain fluctuations. Conclusions: Combined SCS and ITB neuromodulation decreases pain intensity in refractory CRPS cases or improves associated abnormal dystonic posture and movement disorders and reduces pain fluctuations.

Objective: To investigate clinical efficacy as well as the incidence and extent of complications regarding intrathecal baclofen (ITB) therapy in children.Methods: This is a retrospective medical chart review of three paediatric patients with acquired brain injuries (ABI) resulting from drowning who underwent ITB pump implantation for treatment of severe spasticity.Results: Compared to the pre-operative state, ITB therapy reduced spasticity with a corresponding decrease of modified Ashworth scale in upper (3.2 ± 1.4 to 1.3 ± 0.6) and lower extremities (3.5 ± 0.9 to 2.0 ± 1.0). Overall, six complications, five device-related and one accidental, were found in two out of three patients.Conclusion: Intrathecal baclofen is an effective therapy option for paediatric patients with ABI after drowning to significantly reduce spasticity of upper and lower extremities. A word of caution must be addressed to the incidence and extent of complications related to ITB therapy.

DOI: http://dx.doi.org/10.3329/taj.v15i1.8381 TAJ 2002; 15(1): 37-42

Adult upper limb spasticity

Spasticity of cerebral or spinal origin severely impairs an individual's functional ability and quality of life. Intrathecal baclofen (ITB) therapy via an implantable pump is indicated for use in patients unresponsive to oral antispasmodics. ITB therapy improves the daily caring for and relief of painful spasms. In Lithuania, ITB therapy was introduced in clinical practice just recently. We share our experience of spasticity management with the ITB pump system in five patients at Vilnius University Hospital Santariskiu Klinikos. Four patients had spastic tetraplegia associated with cerebral palsy, and one patient developed spastic paraplegia after a spinal epidural abscess.

Spasticity Management in Persons with Disorders of Consciousness.

The primary objective of this study was to determine the frequency and nature of complications that occur during intrathecal baclofen (ITB) therapy, including nonsurgical complications as well as complications associated with both implantation surgeries and subsequent revisions. The authors retrospectively reviewed the medical records of all patients who had baclofen pumps implanted at a tertiary children's hospital from 2006 through June 2019. The study employed appropriate descriptive statistics and statistical models to analyze patient demographics, improvements in tone, and clinical complications. The authors evaluated the associations of complications as well as changes in modified Ashworth Scale (MAS) scores with various preexisting conditions (e.g., presence of gastrostomy tubes [G-tubes] and ventriculoperitoneal [VP] shunts) and surgical variations (e.g., use of newer [Ascenda] catheters and subfascial versus subcutaneous catheter tunneling). One hundred forty-two pumps were implanted. Complications occurred in 111 patients (78.2%). The most frequent complications were catheter complications and pseudomeningoceles, each of which occurred in 63 (44%) patients. On multivariable analysis, pseudomeningoceles and percutaneous CSF leaks were significantly less likely when intrathecal catheters were placed via laminotomy versus spinal needle (OR 4.6, p = 0.044), and when catheters were passed from the posterior incision to the abdominal pump pocket deep to the thoracolumbar fascia rather than superficial to it (OR 2.7, p = 0.008). Preexisting G-tubes and VP shunts at the time of pump implantation were not associated with a significantly increased likelihood of pump malfunction or infection. Ascenda catheters were significantly less likely to have disconnections (p < 0.001) and obstructions (p = 0.016), and overall were less likely to have any catheter-related complications (p = 0.01). Patients with preexisting VP shunts at the time of implantation had a significantly greater mean decrease in MAS scores in both their lower extremities (1.8, p = 0.003) and upper extremities (1.3, p = 0.002) than did patients without shunts. Various complications are associated with ITB therapy, most commonly catheter complications and pseudomeningoceles. There have been fewer catheter complications associated with the newest catheter model, while pseudomeningoceles have become less frequent since the surgical technique was modified to prevent them. VP shunts and G-tubes are not associated with significantly higher complication rates and shunts seem to be associated with greater efficacy of ITB therapy, as represented by a greater mean improvement in MAS scores.

Botulinum toxin A (BONT/A) injections play a central role in the treatment of upper limb spasticity in stroke patients. We proposed structured stretching exercises to enhance the effect of post-stroke spasticity relief of the upper limbs following BONT/A injections. A total of 43 patients who had a stroke with grade 2 spasticity or higher on the Modified Ashworth Scale (MAS) in their upper-limb muscles were randomly assigned to the intervention (n = 21) or control group (n = 22). The former received structured stretching exercises after their BONT/A injections for 20 min, 5 days per week, for 6 months at a hospital, while the others conducted self-stretching exercises at home. The outcome measures were assessed before the intervention (T0) and after three (T1) and six months (T2). Significantly greater improvements in the MAS scores of the elbows, wrists, and fingers were found in the intervention group’s patients at T1 and T2. The behavioral outcome measures, including shoulder pain, activities of daily living, and quality of life, and our electrophysiological studies also showed a significantly higher enhancement in this patient group. In conclusion, the structured stretching exercises plus BONT/A injections for six months showed a superior effect in relieving post-stroke upper-limb spasticity compared to self-stretching exercises.

IntroductionThis case report presents the management of a 62-year-old woman with generalized grade 4 tetanus, focusing on the innovative use of intrathecal baclofen (ITB) therapy. The patient initially presented with...

Oral motor, communication, and nutritional status of children during intrathecal baclofen therapy: A descriptive pilot study

Introduction: Treatment with intrathecal baclofen (ITB) is a therapeutic option in the management of severe spasticity in patients with hereditary spastic paraparesis (HSP). However, information on the impact of ITB on the natural course of disease, especially the effect of ITB on functional parameters over time is limited.Materials and Methods: We evaluated seven patients with HSP retrospectively who were treated with an ITB device. The following parameters were measured before (pre-implantation) and after implantation (post-implantation) of the ITB device at steady state dosage of ITB and annually until last follow-up: modified Ashworth Scale, Reflex Scale, modified Rankin Scale, and Rivermead Mobility Index. The ITB dosages were assessed after reaching steady state as well as annually until last follow-up.Results: The ITB device was implanted 13 ± 6 (range 9–16) years after diagnosis of HSP on average. Severe spasticity was controlled in all patients by a mean baclofen dosage of 188 ± 60 (range 145–230) μg per day at steady state post-implantation. The modified Ashworth Scale improved significantly from 3 (interquartile range [IQR] 3–3.25) to 1 (IQR 1–1.25; p = 0.046), as did the Reflex Scale from 5 (IQR 4.75–5) to 3 (IQR 2.75–3; p = 0.046) at steady state dosage of ITB. The modified Rankin Scale improved from 2 (IQR 2–2) to 1 (IQR 1–1.5; p = 0.083) and the Rivermead Mobility Index remained 14 (IQR 13.5–14 pre-implantation, IQR 14–14 post-implantation; p = 0.18). Post-implantation, spasticity improved for 2–3 years, followed by a stable phase of ambulatory and other mobility functions for 4–5 years. Thereafter, the maintenance or progressive loss of mobility depended on individual courses of the disease. No ITB-related severe side effects occurred.Discussion: Our data further support the role of ITB in the treatment of severe spasticity in patients with deteriorated walking performance suffering HSP. ITB therapy may initially improve spasticity and stabilize mobility functions for the first 6–8 years in patients with HSP.