Intrathecal baclofen for spasticity‐related pain in amyotrophic lateral sclerosis: Efficacy and factors associated with pain relief

Abstract

Clinical signs and symptoms of spasticity include hypertonia, involuntary movements (spasms, clonus), decreased range of motion, contractures, and often spasm-related pain. When spasticity is refractory to medical management, patients may be referred for intrathecal baclofen (ITB) pump placement. We reviewed a cohort of amyotrophic lateral sclerosis (ALS) patients with intractable spasticity requiring ITB to further define the impact of ITB on pain relief in this patient population. From 2003 to 2005, eight patients (mean age 43.8 years; 5 men, 3 women) with ALS received ITB for pain associated with intractable spasticity at our institution. Mean disease duration preoperatively was 47.4 months, mean follow-up was 9.8 months, and pain was evaluated using a 0-10 scoring system. All patients experienced spasticity relief in response to a preoperative bolus test injection of ITB (25-50 microg) via lumbar puncture. Following ITB pump placement, the average reduction of pain was 54% (P = 0.0082). Six patients (75%) experienced pain score reduction, three of whom had complete pain relief. Postoperative pain reduction was predicted by the degree of pain reduction following preoperative ITB test injection. These results support ITB as a treatment modality for pain associated with spasticity in ALS.

Pain in Amyotrophic Lateral Sclerosis: A Neglected Aspect of Disease

“…However, as the cramps progress in intensity and duration, carbamazepine, quinine sulphate, or phenytoin may also be given [35]. With time and the development of spasticity, myorelaxants such as baclofen, a γ -amino-butyric acid (GABA) analog that facilitates spinal motor neuron inhibition, are employed [37, 38]. Oral baclofen is usually administered 2-3 times a day in a 10 mg dose, but can be titrated up to a 4 times per day—20 mg dose if necessary [36, 39].…”

Amyotrophic lateral sclerosis and palliative care: Where we are, and the road ahead

“…The average reduction in pain scale was 54% after placement of the pump. 19 The value of exercise in the treatment of spasticity in ALS patients is unclear. One study of a personalized exercise program in the treatment of ALS-related spasticity showed benefit at 3 months, but this was not statistically significant.…”

“…The most recent AAN practice parameter 11 notes that there are no controlled trials on the treatment of depression or anxiety in ALS, although at least one study suggested that depression is treatable even in the end stages of this illness. 19 Choice of antidepressant should be tailored to the patient's symptoms. Tricyclic antidepressants can be used for sialorrhea as well as mood, although the doses required for antidepressant effect are associated with an increased side effect profile compared with other medications.…”

Racing against the clock: Recognizing, differentiating, diagnosing, and referring the amyotrophic lateral sclerosis patient

“…Although pain is not typically associated with ALS, its presence can be devastating and is likely multifactorial when it occurs, such as in the setting of prominent spasticity. 41 Identification of distal, symmetric sensory loss in a patient with UMN and LMN symptoms and signs should prompt an evaluation of common causes of sensory neuropathy, including diabetes mellitus, thyroid disease, alcohol abuse, paraproteinemia, paraneoplastic disease, connective tissue disease, vitamin B12 deficiency, and copper deficiency. In a patient who has an LMN syndrome beginning in the bulbar region and proximal upper extremities, and who has abnormal sensory nerve conduction studies, X-linked recessive bulbospinal neuronopathy (Kennedy's disease) 42 should be considered.…”