Management of severe spasticity with intrathecal baclofen delivered by a manually operated pump.

Abstract

Intrathecal baclofen abolishes spasticity in many patients with neurological diseases but there are few studies on its long-term effectiveness. Since 1986 a manually operated subcutaneous pump has been used to deliver baclofen intrathecally in 21 patients with a follow up of at least one year. Most patients had multiple sclerosis and all were wheelchair-bound. Sixteen patients had a complete and sustained benefit. In four other patients the treatment was effective in the short term but not in the long term. In the remaining patient the pump never worked. Complications included meningitis, pump failure, erosion through the skin, and baclofen overdose. Nevertheless, only three patients have asked to discontinue the treatment. We conclude that intrathecal baclofen, delivered by a manually operated implanted pump, is an effective treatment for severe spasticity in most patients. drugs by mouth at the maximum tolerated doses; (b) leg spasticity or spasms which interfered with everyday life as judged either by the patient or their carer; (c) a good response of the spasticity or spasms to an intrathecal bolus of baclofen; and (di) informed consent of the patient and family. OUTCOME MEASURES Hypertonia, spasms, and the improvement in quality of life as judged by the patient and carers were used as the three main measures of outcome. Tone was measured using the Ashworth scale.3 This is an ordinal scale which grades tone in the muscle between 1 (normal) and 5 (where the limb is fixed). Care was taken to exclude fixed contractures due to muscle shortening. Hip flexion, extension, and abduction, and knee flexion and extension were tested in all patients. The three worst movements from each leg were summed to give the patient's spasticity score. Spasms were scored for each leg: 0 for absent, 1 for movement-induced, 2 for touch-induced, and 3 for spontaneous. The sum of these scores gave the patient's spasm score. We determined the Barthel index and asked patients and carers specific questions about sitting, bathing, toileting, and dressing as we found this more sensitive than complex quality of life scales in measuring ease of care-giving. INTRATHECAL BACLOFEN INJECTIONVarious strengths of baclofen injection ranging from 50 to 3000,ug/ml were prepared in batches by the central pharmaceutical production unit, Royal Victoria Hospital, using baclofen powder obtained from either CibaGeigy or Bufa BV. Where patients required different strengths from those available these were prepared aseptically in the pharmacy department, Royal Victoria Hospital by diluting a more concentrated injection. Most patients were started with an injection of 50 ,ug given at lumbar puncture. Tone and spasms were assessed at three hours and, if the spasticity score was not reduced to between six and 12 or spasms were not completely abolished, the procedure was repeated at intervals of two days using increasing doses of baclofen up to a maximum dose of 300 ,ug. Most patients responded to 200 ,ug or less. The pump delivers a bolus of 0 1 ml when ...

Intrathecal baclofen for dystonia: Benefits and complications during six years of experience

“…13. The presence of mild-moderate side effects, such as sedation or nausea, in the face of clinical improvement was not regarded as a contraindication to ITB because these adverse effects can often be ameliorated with careful dose titration.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]37 Significant benefit has been demonstrated as a reduction in tone and spasticity, and is also reflected in studies of quality of life, activities of daily living, level of function, and cost-effectiveness. 12,16,18,38 ITB may be considered as an option for selected patients with intractable dystonia.…”

“…8,9,[51][52][53] Improvements in technology, and education and experience of both the patient and the healthcare provider may reduce the occurrence of these events in the future.…”

Treatments for spasticity and pain in multiple sclerosis: a systematic review

“…Lazorthes and colleagues 70 reported similar findings. On the other hand, Patterson and colleagues 71 found no change in the Barthel index, despite substantial improvements in the Ashworth and spasm scores.…”

Intrathecal baclofen withdrawal simulating neuroleptic malignant syndrome in a child with cerebral palsy

“…The use of intrathecal baclofen was introduced in 1984, when Penn and Kroin published the first clinical evidence that it significantly reduced spasticity in selected patients with spinal cord injury and multiple sclerosis (Penn and Kroin 1984). Subsequently, intrathecal baclofen infusion (IBI) has been found to be safe and effective in adult patients with spasticity of spinal and cerebral origin (Penn 1992, Coffey et al 1993, Lewis and Mueller 1993, Abel and Smith 1994, Patterson et al 1994, Rifici et al 1994, Azouvi et al 1996, Becker et al 1997, Meythaler et al 1997, Middel et al 1997.…”