Oral Baclofen and Clonidine for Treatment of Spasticity in Children

Lubsch, Lisa; Habersang, Rolf; Haase, Mark R.; Luedtke, Sherry

doi:10.1177/7010.2006.00134

Cited by 27 publications

(14 citation statements)

References 10 publications

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“…31 A few studies have supported the use of clonidine, which appeared to be particularly effective in our patient. 28 Certainly, the high drug doses required to control spasticity may be beyond the current evidence base. 28 Pharmacotherapy is further complicated by the coexistence of spasticity and dystonia, which may reduce treatment effectiveness.…”

Section: Discussionmentioning

confidence: 99%

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Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Waqar

Ellenbogen²,

Kumar³

et al. 2014

PED

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Intrathecal baclofen (ITB) is a reversible treatment that reduces muscle tone to ameliorate spasticity and dystonia in patients with cerebral palsy (CP). The resulting decrease in energy expenditure allows patients to gain much-needed weight, albeit temporarily. Modern techniques require sufficient abdominal musculature and subcutaneous fat to permit the implantation of an indwelling pump. In patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection. The authors describe a variation of the classical procedure in a young patient with severe cachexia. A 10-year-old boy with spastic-dystonic quadriplegic CP was admitted to the neuromedical unit. Numerous drug trials had failed, and surgical intervention was deemed necessary but was complicated by his cachectic body habitus. The authors inserted a lumbar intrathecal catheter and subcutaneously tunneled it to the anterolateral abdomen, where it was connected to a subcutaneous injection port. Baclofen was continuously infused into the subcutaneous port using a noncoring needle connected to an external pump. The needle and line were changed every 5 days to minimize the risk of sepsis. Although other techniques, such as intraventricular baclofen delivery, have been described, these are largely dependent upon sufficient musculature to support a visceral pump. A subcutaneous injection port system represents an alternative approach that reduces the risk of sepsis and may be better tolerated in cachectic patients.

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Section: Discussionmentioning

confidence: 99%

“…28 Certainly, the high drug doses required to control spasticity may be beyond the current evidence base. 28 Pharmacotherapy is further complicated by the coexistence of spasticity and dystonia, which may reduce treatment effectiveness. 10 For these reasons, neurosurgical management may be warranted in a subset of patients.…”

Section: Discussionmentioning

confidence: 99%

Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Waqar

Ellenbogen²,

Kumar³

et al. 2014

PED

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“…5 Adding clonidine to epidural local anaesthetic has theoretical advantages. It is used in the treatment of spasticity 19,20 and epidural clonidine has been shown in itself to be analgesic. 21 Clonidine enhances both sensory and motor block from epidural local anaesthetic.…”

Section: Discussionmentioning

confidence: 99%

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Chalkiadis

Sommerfield

Low

et al. 2015

Develop Med Child Neuro

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AUCArea under the curve SEMLS Single-event multilevel surgery AIM To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.METHOD Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).RESULTS There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).INTERPRETATION Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.Cerebral palsy (CP) by definition is a disorder of movement and posture, caused by a non-progressive brain injury or lesion. 1 However, although the causative brain lesion is defined as a static encephalopathy, the musculoskeletal pathology in the limbs is progressive during the child's growth and maturation, with the development of contractures, bony torsion, and joint instability. Children with CP may undergo extensive orthopaedic surgery of the lower extremities to correct deformity and improve function. Single-event multilevel surgery (SEMLS), defined as at least one surgical procedure, performed on two different anatomical levels (hip, knee, or ankles), has been shown to result in dramatic improvements in gait and functioning, which are sustained at 5-year follow-up and reduce the need for serial surgeries and periods of rehabilitation. 2,3 Good pain control is important for patient comfort and facilitates early rehabilitation and discharge. Effective pain management is challenging because of multiple surgical incisions, associated comorbidities (chronic lung disease, risk of aspiration, epilepsy, gastro-oesophageal reflux), and impairments in communication and/or cognition that may make pain assessment difficult. In addition, the surgical nociceptive input is likely to lead to wind-up of spinal reflexes and worsening of muscle spasm 4 and possibly to an escalating pain-spasm cycle. Epidural analgesia is the preferred modality of regional anaesthesia in our institution but there are limited data...

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“…Stimulants such as methylphenidate, a commonly used treatment for ADHD, may also be efficacious in neurological dysfunction post-traumatic brain injury (56); baclofen, most closely associated with CP, may be useful for management of spasticity regardless of cause (57), while clonidine, often used adjunctively in ADHD, may also be useful for spasticity following brain injury (58). Similarly, psychopharmacological agents including the so-called antipsychotic drugs are used in management of children with various neurodevelopmental conditions to help control aggressive behavior, agitation, or irritability (59, 60), just as the SSRI “antidepressants” are useful in management of anxiety and/or compulsive and repetitive symptomatology (61) in the absence of psychosis or depression.…”

Section: Theme 2: Disease and Disability Perspectives: Their Goodnessmentioning

confidence: 99%

Perspectives on “Disease” and “Disability” in Child Health: The Case of Childhood Neurodisability

Miller

Rosenbaum

2016

Front. Public Health

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Chronic health conditions are often associated with what is termed disability. Traditional thinking has focused on diagnosis and treatment of chronic diseases and disorders, with less attention to people’s functional abilities and their contextual determinants. Understanding all of these factors is integral to addressing the predicaments and needs of persons with chronic conditions. However, these complementary yet distinct “worldviews” reflected in what we call disease and disability perspectives often remain, at best, only vaguely articulated. In this paper, we explore and expand on these perspectives in light of conceptual advances, specifically the framework of the World Health Organization’s International Classification of Functioning, Disability and Health, and their epistemic underpinnings with reference to Wilhelm Windelband’s notions of nomothetic and idiographic types of knowledge. Our primary focus is the children with neurodisability – life-long conditions that onset early in life and have functional consequences that impact developmental trajectories. We critically review and analyze conceptual material, along with clinical and research evidence relevant to the experiential and clinical realities of this population, to demonstrate the limitations of a biomedically based diagnostic–therapeutic paradigm at the expense of a developmental and disability-oriented perspective. Our main aim in this paper is to argue for an explicit recognition of both disease and disability perspectives, and a more balanced and appropriate deployment of these concepts across the continuum of clinical services, research, policy-making and professional and public education in relation to children with neurodisability; we also provide concrete recommendations to advance this progressive strategy. The relevance of these aims and strategies, however, extends beyond this particular population.

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Oral Baclofen and Clonidine for Treatment of Spasticity in Children

Cited by 27 publications

References 10 publications

Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Perspectives on “Disease” and “Disability” in Child Health: The Case of Childhood Neurodisability

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