Baclofen

ABSTRACT

Intrathecal baclofen (ITB) is a relatively new treatment approach that may be useful for treating spasticity in patients with chronic stroke. In this paper, we examine ITB treatment of spastieity caused by stroke and the implications for physical therapy management. We also present ITB pharmacology, side effects, and the screening procedure.

INTRODUCTION

In the United States, stroke is the third most common cause of disability and death after heart disease and cancer.1,2 Every year there are approximately 700,000 new cases of stroke and about one-third of patients die from the incident.1,3,4 Stroke is defined as acute neurological dysfunction of vascular origin that lasts more than 24 hours and has signs and symptoms corresponding to the involvement of focal areas of the brain.5 Almost 75% of patients with stroke have motor impairments, resulting in disability, such as impaired transfer, pain, contractures, gait abnormalities, sleep disorders, and the inability to perform activities of daily living, all of which compromise safety.6-12

Spasticity develops in nearly 65% of patients with stroke and while it is a major cause of disability, in some cases it is beneficial in helping the patient stand or ambulate.13,14 Spasticity is assigned different meanings. However, a frequently cited definition proposed by Lance15 describes spasticity as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflexes. It is one component of the upper motoneuron syndrome and may interfere with voluntary motor function in patients with residual muscle power.15,16

Current management of spasticity includes passive stretching, strengthening, physical modalities, splinting, biofeedback, cold, and electrical stimulation. These treatments have limited results.17,18 Pharmacological management of spasticity includes peripherally acting drugs such as botulinum toxin and dantrolene sodium or centrally acting drugs such as oral baclofen, diazepam, tizanidine, and clonidine.9-11,19,20 When physical, occupational, and medical management of spasticity fails, the patient with stroke may elect surgical management, such as intrathecal baclofen.21,22

Continuous intrathecal baclofen (ITB) was introduced 2 decades ago to treat spasticity, and its beneficial effect has been well documented.23-26 Baclofen is infused via a subcutaneously placed programmable pump.23,27 The pump is implanted in the abdominal wall (Figure 1) with a catheter threaded into the subarachnoid space, at L1-2 and subsequently threaded as high as T-6. Intrathecal baclofen has been reported in the management of spasticity in stroke,28,29 cerebral palsy,30 spinal cord injury,31,32 and amyotrophic lateral sclerosis.33-35 Francisco describes the perfect ITB candidate as one who has had "a stroke with severe, functionally limiting, multijoint spastic hypertonia and predominant involvement of the lower limbs, and one who cannot either tolerate the effects of oral drugs or respond to adequate doses of other therapies."36

The reminder of this paper will examine ITB treatment of spasticity caused by stroke and the implications for physical therapy management. Spasticity management in spinal cord,37 multiple sclerosis,38 and cerebral palsy3'9 are reviewed elsewhere and are beyond the scope of this review.

BACLOFEN AND ITB PHARMACOLOGY

Baclofen (Lioresal®) is an agonist at the gamma-aminobutyric acid (GABA)-B receptor subtype with little or no action at the GABA-A or GABA-C subtypes.40-44 Baclofen acts predominately at the spinal level and attenuates motor output, especially on high frequency, and reflexively mediated muscle activity (ie, spastic motor activity). It inhibits both monosynaptic and polysynaptic reflexes possibly by decreasing excitatory neurotransmitter release from primary afferent terminals, although actions at supraspinal sites may also occur and contribute to its clinical effect.45

One advantage of intrathecal baclofen is that it allows effective cerebrospinal fluid (CSF) concentrations to be achieved with resultant plasma concentrations of 100 times less than those seen with oral administration.23,46 In addition the programmable pump used to deliver the baclofen allows for numerous dose adjustments that are needed during treatment. However, adverse effects of general CNS depression may still appear as indicated by sedation with tolerance, somnolence, ataxia, and respiratory and cardiovascular depression.

Selecting an ITB Candidate and Screening Protocol

According to Meythaler and colleagues,28,29 the ideal candidate is a patient with stroke who presents with severe chronic spasticity in the lower or upper extremities rated at 3 or 4 on the Ashworth47 scale (5-point scale) and an average of at least 2 on the Penn23 Spasm 4-point scale in the affected extremity, as well as having had intolerable CNS side effects with oral antispasticity agents.28,29 Specifically, the patients who use extensor tone to stand and have trunk control in unsupported bench sitting will demonstrate improvement in function with ITB therapy.48 Whereas those patients who move with hip and knee flexion and ankle dorsiflexion will not show the same success. However the appropriateness of the continuous ITB pump has not been established for patients' with seizures, ventriculoperitoneal shunts, or implantable, programmable medical devices (eg, spinal cord stimulators, pacemakers).

Prior to pump implantation, each patient undergoes an "intrathecal baclofen screening trial."28,29 It begins with an initial Ashworth screening often performed by the physical therapist, followed by a 50 µg intrathecal injection.48 The onset of action of baclofen in adults is generally 1/2 to 1 hour after intrathecal bolus administration. Peak spasmolytic effect is seen approximately 4 hours after dosing and effects may last 4 to 8 hours. Onset, peak response, and duration of action however may vary with individual patients depending on the dose and severity of symptoms.49,50 The Ashworth screening may then be repeated every 2 hours for the next 8 hours. If Ashworth scores do not drop, a higher dose (75 µg) is given on the next day.48 A third day may be necessary with a bolus injection of as much as 100 µg. The recommendation for permanent pump placement (ie, continuous ITB) is based on reduction in the subject's Ashworth scale or Penn Spasm score by 2 without the development of side effects.28,29 Hypotonia, even if greater than desired is a positive result on the screening test.48 However, it must be explained to the patient that the hypotonia is due to receiving the full dose of baclofen all at once via injection as opposed to being slowly titrated with the pump.

After the pump and catheter arc implanted the patient is asked to remain flat for a few days.48 This helps to prevent headaches and cerebral spinal fluid leaks. Other precautions include observing for any swelling over the pump or incision area. The patient may wear an ace wrap around the abdomen or an abdominal binder. These interventions are used to reduce swelling and also help the patient adjust to the change in muscle tone particularly in the upright position for the first few weeks. The patient is usually discharged from the hospital within 1 week only to return for intensive therapy as an outpatient following wound healing. Prior to discharge however, transfers and ambulation are assessed, and assistive devices may be adjusted so that that the patient can function safely.

IMPLICATIONS FOR PRACTICE

After pump implantation, the physical therapist should set goals that account for the patient's lower muscle tone. Transfers and mobility will feel different to the patient and may be more difficult to execute successfully. Splints will need to be reassessed as well as seating systems, and new assistive devices may be considered.

Therapy initially may be complicated by the fact that the pump will need frequent adjustments to titrate the dose of baclofen for proper response. A reduction in muscle tone is desired but weakness and sedation are unwanted. The ITB infusion pump is programmable so it can be set to provide a lower dose of baclofen during the day to allow the patient to use extensor spasticity in the lower extremity to stand and to minimize sedation. A higher dose can be programmed at night to decrease muscle spasms and allow the patient to sleep. Multiple dose adjustments over several months are usually needed to achieve the regimen that is most effective.28,29,50

Research has shown that ITB is effective at producing a significant drop in the Ashworth score and the average spasm score in patients with chronic stroke and those with acquired brain injury.26,28 However, the reduction in muscle tone is generally more profound in the lower extremities than in the upper extremities.51-53 Physical therapy continues to be necessary in the early postoperative period to address the reduction of muscle tone, spasticity, and spasm as well as the lack of improvement in the upper extremities. Treatment interventions include using partial body weight support,54-58 biofeedback,59-62 functional electrical stimulation, neuroprotheses application,63,64 constraint-induced therapy,65-70 and virtual reality.71-73 In addition many patients now find that traditional strengthening is emphasized whereas it was not a focus of their treatment plan prior to pump implantation. Most activities are okay to perform after pump placement with the exception of contact sports or any activity in which there is a risk of trauma to the pump and/or catheter. Forceful trunk rotation is also contraindicated because of the possibility that the catheter may dislodge. The use of heat modalities near the pump or catheter is also prohibited as is the use of hot tubs, saunas, scuba diving, and hyperbaric oxygen.48 These activities might alter the rate at which baclofen is dispensed.

The goals of therapy should be clearly identified and include increasing functional capacity, relieving discomfort, phasing out physical therapy intervention and phasing in everyday activities. Once determined, these goals should be very clear to everyone involved in the patient's care especially the patient. An unrealistic or unspoken expectation by patient, family, and/or carcgiver often leads to disappointment, depression and interpretations of treatment failure.

Effect of ITB on the Less Involved Side

The reflexes on the less involved side are affected by short periods (3 months) of ITB in patients with stroke.29 Furthermore, with continuous ITB (1 year) Meythaler et al reported that the reflex score decreased, but the reduction was not as significant as in the extremities affected by the stroke.28,29 Moreover, muscle strength, using the standard 1-5 motor assessment, did not reveal motor weakness of the less involved side nor did the patient or family notice a drop in the patient's strength.28,29 Francisco36 argued that the less involved limb did not become weak after ITB for 2 reasons. First, ITB probably has a selective effect on certain spinal cord receptors that also receive supraspinal input that is modified by cerebral disease. Second, the amount of infused baclofen is so small that it does not cause significant clinical muscle weakness.36 Currently, there is no conclusive evidence to recommend strengthening the uninvolved upper and/or lower extremities.

Measuring Spasticity versus Functional Improvement after ITB

Reduction of spasticity and spasm are presumed to improve active functional movements.25,28,29,42,74 However, not all research supports that assumption.13,75-77 The general assumption that once spasticity diminishes there will be improvement in voluntary motor function has been challenged. Some authors have noticed that with diminished spasticity there is improvement in function as demonstrated by progressing from wheclchair dependence to independent ambulation with assistive devices.28,29 In addition, patients exhibit easier dressing, diapering, transfer, orthotic wear, and sitting tolerance in almost 90% of cases that receive ITB.74 Similar results were reported for tnrombotic stroke42 and for children with CP.25 Other research suggests that reduction of spasticity may impair motor function if the patient relies on spasticity for support during walking and standing.13,76 Similarly, a recent study reported significant reduction in muscle tone without improvement in motor function when treating finger flexor hypertonia in patients with stroke using botulinum toxin (ie, patient may be able to open the hand to grip but no longer have the strength to hold the object).75

Inappropriate outcome measures have been touted as one reason why functional improvements may not always correspond with successful reduction in tone.78 An outcome measure must be sensitive enough to detect changes in functional improvement. Using the Ashworth scale,47 Muscle Spasm scale,23 and reflex scale to detect changes in function is not be appropriate since they do not measure functional improvement but instead evaluate selected impairments. The impairments measure can convey whether ITB was effective in reducing tone. But, using a measure that captures an overall functional change, that is of interest to the patient and family, may be more appropriate. Some examples of functional performance evaluations include the Functional Independence Measure (FIM),79 Barthel Indices,80-82 Nottingham Health Profile (NHP),83 and the Timed Up and Go test.84 Another appropriate outcome measure is the Canadian Occupational Performance Measure (COPM), a disability measure, which is used to evaluate performance and satisfaction relative to individualized problem areas as defined by the subject or his famly.85,86 Although the COPM has not been used as an outcome measure in patients with stroke, it has been tested and used in other patient populations.87-89

ITB Complications

Continuous ITB has been an effective treatment for patients with stroke who did not respond well to oral medication for spasticity. Both oral medication and ITB have risks, and the physical therapist should be aware of the most common complications that can affect the patient (Table 1).90,91 Abrupt discontinuation of ITB is a cause for concern since this may result in fever, altered mental state, exaggerated return of spasticity, and rigidity.90 Reasons for the abrupt termination may be attributed to a malfunctioning catheter, low drug volume in the pump, battery failure, and of course human programming errors. Early signs of withdrawal include return to baseline spasticity, pruritis, hypotension, and paresthesias. Late signs of withdrawal resemble autonomie dysreflexia or malignant hyperthermia and can be fatal. Emergency treatment includes administration of an GABA agonist. Therapists should encourage the patient to keep their scheduled refill visits and educate them on the symptoms of baclofen withdrawal. Intrathecal baclofen overdose is rare but will cause drowsiness, dizziness, respiratory depression, seizures, loss of consciousness, and coma.90

The therapist also should be aware that there are complications associated with ITB bolus screening test doses. In 1002 test doses, nausea and vomiting (2.6%), sedation (2.2%), urinary retention (1.6%), hypotension (1.2%), seizures (0.2%), and headache (0.1%) were seen.74 The longterm complications seen in 936 subjects after implantation was performed were infection (1.7%), scroma (cerebrospinal fluid collection) (0.8%), hydrocephalus (0.2%), and seizures (0.1%).74 Finally, the most common reason for pump replacement was infection and battery failure (1%).74 A similar study followed up on the effects of ITB in 75 subjects diagnosed with spinal cord injury or multiple sclerosis over a period of 5 to 41 months after pump implant.91 The authors reported 12 patients developed drug-related symptoms, 6 developed wounds, and 3 developed pump problems.90 These studies found that the short- and long-term complications for ITB did not exceed 2.6 for any single complication.

In summary, ITB reduces spasticity; however, it is invasive and considered an expensive mode of treatment that requires close monitoring of the pump and the patient. It is necessary for physical therapists to be familiar and monitor these complications in their patients. Finally, the potential benefits associated with continuous ITB outweigh its risks.

CONCLUSION

Physical therapists encounter situations in which spasticity is responsible for major disability in patients with stroke.6 In addition to careful goal setting, spasticity management following stroke requires a skillful combination of treatment modalities to achieve the best outcome. The consequences of reducing spasticity should be assessed, and treatment of spasticity should be considered when it causes pain or interferes with such functions as ambulation, transfers, and activities of daily living. If spasticity offers stability to a joint and acts as a prop for the limbs, its reduction may only jeopardize the patient's functional capacity.14,75,76 On the other hand, if there is minimal weakness with predominant spasticity, its treatment "will result in tremendous improvement in functional capability for the patient.28 Physical therapy along with antispasticity drugs and surgical management remain the corner-stone in management of patients with spasticity.

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Mohamed Ibrahim, PT, MS, NCS1

John Wurpel, PhD,2

Barbara Gladson, PhD, PT, OTR3

1 Assistant Professor, Physical Therapy Program, SUNY-Downstate Medical Center, Brooklyn, NY (Mohamed.ibrahim@downstate.edu)

2 Associate Professor, St. John's University, Dept of Pharmaceutical Science, Jamaica, NY

3 Associate Professor, Doctoral Program in Physical Therapy, University of Medicine and Dentistry of New Jersey, Newark, NJ

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