Use of intrathecal baclofen therapy in ambulant children and adolescents with spasticity and dystonia of cerebral origin: a systematic review

Abstract

ITB Intrathecal baclofenAIM Studies on the use of intrathecal baclofen (ITB) for ambulant adults with spasticity and ⁄ or dystonia of cerebral origin are scarce, and are even more limited for children and adolescents. This systematic review investigates the use of ITB to improve walking, transfer ability, and gross motor activities in ambulant children and adolescents with spasticity and ⁄ or dystonia of cerebral origin.METHOD Electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, full Cochrane Library, and PEDro) were searched from the earliest date available until March 2011 using combined subject headings and free text if supported by the databases. Studies were included if they had examined individuals who: (1) received ITB therapy by any method (bolus injection, an external delivery system, or an implanted pump); (2) had spasticity and ⁄ or dystonia of cerebral origin; (3) were able to ambulate with or without a walking device, i.e. individuals with cerebral palsy (CP) who were in levels I to III of the Gross Motor Function Classification System or individuals with similar functional mobility if they did not have CP; and (4) were aged 18 years or under. Publications in English in peer-reviewed journals reporting any type of research design, except reviews and expert opinions, were included. Studies were excluded if participants had spasticity and ⁄ or dystonia of spinal origin and if baclofen was administered only orally. Studies that compared ITB with other interventions such as botulinum toxin were also excluded.RESULTS Two independent reviewers scored 16 studies against the guidelines for developing systematic reviews from the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM).INTERPRETATION Fifteen studies were of levels IV or V evidence and only one of level II according to the evidence levels of the AACPDM guidelines, but all were of low quality. No study was found on the use of ITB in ambulant children or adolescents with dystonia of cerebral origin. Not all studies used objective outcome measures to assess the ambulation, transfer ability, and gross motor activities of the participants. A proportion of participants showed improvement in all these areas but adverse events were common. A proportion of participants compromised their ambulatory and transfer abilities after ITB. There was no evidence to support the clinical use of ITB in ambulant individuals with hypertonicity without further rigorous longitudinal studies.Spasticity is a velocity-dependent increase in resistance of a muscle when stretched, 1 and is one of the common signs of an upper motor neuron lesion. Spasticity can make movements difficult and inefficient, which in turn contributes to the formation of contractures, discomfort, and muscle spasms, and thus interferes with activities of daily living such as feeding, toileting, dressing, and positioning. 2,3 One of the pharmacological agents used in treating spasticity is baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). 4 Baclo...

Characteristics of Pain in Children and Youth With Cerebral Palsy

“…A number of treatments exist for dystonia, ranging from oral medication (trihexyphenidyl, baclofen), botulinum toxin, intrathecal baclofen pumps, and, more recently, deep brain stimulation, to help prevent children from becoming "stuck" in painful postures. [18][19][20][21] Response to treatment of dystonia is often variable and patient-specific. Therefore, developing and enhancing the effectiveness of treatments for dystonia is a high priority for future research.…”

Dose-dependent Changes in Gait Pattern after Intrathecal Baclofen Bolus Injection in Adult Ambulatory Cerebral Palsy: A Case Report

“…On the other hand, considering that spasticity has occasionally a positive impact in the clinical field and that spasticity may help to stabilize gait and compensate for muscle power, the reduction of spasticity is not always followed by improvement in function. 9 Therefore, in adult ambulatory CP, it is important to test a patient's gait pattern and functional changes with ITB bolus injection before the placement of the ITB infusion pump.…”

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

“…22,27,42 Intrathecal baclofen is a reversible alternative that can be used in patients with dystonia and is usually preferred to SDR. 35 The selection for this procedure is usually based on a trial ITB period with drug delivery via lumbar puncture or an external pump.…”

“…11 Evidence for ITB therapy is currently limited, 14,35 but initial experiences are promising, 13,26 even in nonambulant patients. 17 However, indwelling devices are difficult to implant and poorly tolerated by patients with low muscle bulk, who require special consideration of implantation site and sepsis risk.…”