The Underutilization of Intrathecal Baclofen in Poststroke Spasticity

Abstract

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.

Poststroke Spasticity Management

“…52 Possible reasons for ITB underutilization include surgical risks, excessive weakness, less effect on upper limbs, and limited functional improvement. These concerns are alleviated by recent studies that conclude that the benefits of ITB therapy outweigh the risks.…”

Neuromodulation Using Intrathecal Baclofen Therapy for Spasticity and Dystonia

“…Other studies demonstrated similar findings. 11,12,14,19) It is still unclear why the uninvolved limbs are not affected by ITB, at least clinically. Perhaps ITB has a selective effect on certain spinal cord receptors that also receive supraspinal input modified by the cerebral disease.…”

Does Every Patient Require an Intrathecal Baclofen Trial Before Pump Placement?

“…In summary, many patients have the potential to benefit from ITB therapy. Patients with some disease process may even be undertreated with regard to this intervention [3,4]. The screening trial may be beneficial for some individuals, however, to suggest that a patient could not benefit from this powerful intervention without first undergoing a screening trial is a bar set too high.…”