The Underutilization of Intrathecal Baclofen in Poststroke Spasticity
Aurora Medical Center Summit, Summit, Wisconsin, USA.Topics in Stroke Rehabilitation (Impact Factor: 1.45). 05/2011; 18(3):195-202. DOI: 10.1310/tsr1803-195
Stroke is one of the leading causes of adult disability in the United States, with a reported prevalence of 6.4 million people. Spasticity is one of the clinical features of the upper motor neuron syndrome seen after a stroke. The prevalence of spasticity after a stroke ranges from 17% to 42.6%, and an average of two-thirds of people with spasticity have upper and lower extremity involvement. Oral medications and botulinum neurotoxin injections are current treatments for problematic spasticity. However, these treatments are often limited by side effects or dose ceilings. Intrathecal baclofen (ITB) is a proven method for the management of disabling spasticity from multiple etiologies. Studies have demonstrated improved mobility, activities of daily living, and quality of life in spastic poststroke patients. Despite the benefits of ITB, fewer than 1% of stroke patients with severe disabling spasticity are being treated with ITB. This article will review the prevalence of severe poststroke spasticity and the rate of ITB use and will discuss reasons for its limited use in stroke survivors.
Full-textDOI: · Available from: Nicholas Ketchum, Jun 18, 2014
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ABSTRACT: Assess spinal reflex excitability after increasing intrathecal baclofen (ITB) flow by manipulation of drug concentration and mode of administration. The effect of concentration was assessed by comparing changes in H-reflex (H/M ratio) 1-6h after a 50μg ITB bolus at 50μg/ml concentration administered manually via lumbar puncture (LP, duration 1-2min, n=27) to a 50μg bolus at 500μg/ml concentration programmed through the pump and delivered via intrathecal catheter (IC, duration 10min) above simple continuous dose (25-100μg/day, n=16). The effect of mode of administration was assessed by comparing peak changes in H/M ratio after 50μg IC bolus above simple continuous dose (complex continuous mode, n=27) to simple continuous mode only (n=22) at equivalent daily doses (75-150μg/day). H/M decrease was faster and overall greater after LP than IC bolus (mean 1-h 77% vs. 63%, p=0.012; 1-6h 91% vs. 82%, p<0.001, respectively). H/M ratio also decreased significantly more with complex (91%) than simple continuous mode of administration (78%, p=0.025). Lower ITB concentration and complex continuous mode of administration lead to greater decrease in H/M ratio. Decreased spinal reflex excitability after adjustment of drug and pump parameters to increase ITB flow may result in better clinical response.Clinical Neurophysiology 05/2012; 123(11):2200-4. DOI:10.1016/j.clinph.2012.04.007 · 3.10 Impact Factor
Article: Poststroke Spasticity ManagementStroke 09/2012; 43(11):3132-6. DOI:10.1161/STROKEAHA.111.639831 · 5.72 Impact Factor
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ABSTRACT: Background: The long-term management of lower limb spasticity after stroke is an important aspect of an individual's physical recovery and quality of life. Objective: To examine the effectiveness of pharmacological interventions in reducing spasticity of the lower limb in chronic stroke survivors. Methods: PubMed, CINAHL, and EMBASE were searched for studies in which (1) ≥50% of the sample size had sustained a stroke; (2) the research design was a randomized controlled trial (RCT); (3) the mean time since stroke was ≥6 months for both the treatment and control groups, at the time treatment was initiated; (4) the treatment group received a pharmacological intervention aimed at treating lower limb spasticity; and (5) spasticity was assessed pre and post treatment. Methodological quality of each study was assessed using the PEDro tool. Results: Nine RCTs (PEDro scores, 4-9) met inclusion criteria and included a pooled sample size of 605 individuals with a mean age of 54.8 years (range, 14-86). Four RCTs provided evidence that botulinum toxin type A was effective in reducing spasticity compared to persons receiving placebo or a phenol neurolytic. One study provided evidence that both alcohol and phenol neurolytics were effective in reducing spasticity. Finally, 4 studies provided evidence that oral and intrathecal medications were effective in reducing lower limb spasticity compared to placebo. Conclusions: Pharmacological treatment initiated 6 months post stroke reduced lower limb spasticity. Relevant areas of exploration for future research could include the period of effectiveness, long-term complications, and a cost-benefit analysis of such treatments.Topics in Stroke Rehabilitation 11/2012; 19(6):479-90. DOI:10.1310/tsr1906-479 · 1.45 Impact Factor