Intrathecal baclofen therapy: Reduce spasticity, improve patients’ life
Dr. med Peter Koßmehl is a neurologist working at the neurological rehabilitation clinic in Beelitz. 60-80% of his patients are stroke patients, from these, approximately 5% are suffering with severe spasticity. In the interview below, Dr. Koßmehl explains how severe spasticity develops, what consequences this has for the patients, and how symptoms can be decreased significantly on the basis of new study results.
How do patients develop severe spasticity after a stroke?
"Movement disorders are a common impairment after a stroke. The key word for the development of severe spasticity is “Upper Motor Neuron Syndrome”: the injury of the first motor neuron, the part of the central nervous system, which controls the volitional movement, has serious effects. Important signals between the nervous system and the muscles are interrupted. This then leads, on one hand, to a hardening and stiffening of the muscles and, on the other hand, to involuntary muscle contraction (spasm)."
Which signs, existing in the early phase after the stroke, indicate a development of spasticity in the future?
"This depends on which brain area and how many brain tissues has been affected by the stroke. There are, individually, big differences. From a clinical stand point, a muscle hypertonia, which is an increased muscle tone against passive movement, is an early predictor. A right positioning of the patient and an early therapeutically intervention can have a positive effect. Studies showed that 20-30% of the patients develop an increase of muscle tone requiring treatment."
When does spasticity normally develop?
"A wide time frame of onset is possible. Patients with an early progression already develop spasticity on the stroke unit and show up with spasticity in rehabilitation. Mostly, the spasticity develops after 4 to 6 weeks after the acute stroke."
What reduction in functions can be ATTRIBUTED TO spasticity after stroke?
"Mainly, we are speaking about a functional disorder on one side after the stroke. There are patients who don´t have a total paresis on one side, but they can´t use their extremities, for example, to grab with their hand due to cramped muscles. The arm or leg will be functionless. Other patients suffer from a total paresis at the same time as spasticity. In this case, it´s important to keep the joints moving to prohibit contractures, which would cause hygiene and carer problems."
How does spasticity impact the life of patients?
"Spasticity can cause intense pain. Due to an abnormal posture, like contracted hand positions, patients are stigmatised. They feel everyone else is looking at them and thinking ‘why does that person’s hand look like that?’
Alongside reduced mobility, dejection and depression are common consequences after stroke. Patients often retreat from social life."
If there is no cure for severe spasticity, how significantly can the symptoms be decreased?
"With a multidisciplinary treatment, the symptoms can be managed. Medicines alone will not be enough; experienced physicians, physio and occupational therapists are needed, as they can assess changes after an intervention, like a medical treatment, and transfer them into an active training programme. If these treatments are combined, we see encouraging progression."
What does a graded therapy of post-stroke spasticity look like today?
"The Royal College of Physicians in the United Kingdom published guidelines for the management of spasticity which includes patients with post-stroke spasticity. The first step is to always prevent factors which can trigger spasticity. If spasticity is present, the second step is to define the spasticity to help make a decision about the right therapy to decrease the muscle tone. At this time, the guidelines recommend botulinum toxin injections for focal or multifocal spasticity, ITB therapySM for the treatment of more diffuse spasticity and oral medication for a generalised "spasticity". New results like the randomized, controlled SISTERS trial may lead to a different treatment scheme in the future."
What are the advantages or disadvantages of ITB therapySM when compared to the oral baclofen treatment?
"The oral baclofen treatment is non-invasive but has the disadvantage of requiring a higher amount of medicine to achieve an effective treatment. Due to the oral administration, the medicine must go through the whole systemic system. Therefore, the doses must be higher, which can cause side effects. One of these side effects, which heavily affects the rehabilitation process, is fatigue.
With ITB therapySM, the medicine will be delivered directly into the spinal fluid. The patients need a lower dose, which can be administered in microgram changes depending on patient needs, therefore, side effects are a lot lower."
In your opinion, when is the right time to treat post-stroke spasticity with ITB therapySM?
"At the very least, ITB therapySM should be used once a high degree of generalised spasticity has been developed and conventional treatments, such as physiotherapy and medication, can´t further reduce spasticity, but I am saying at the very latest. The new results from the randomized, controlled SISTERS study showed that the muscle tone after stroke can be treated efficiently with the ITB therapySM when compared to oral medication (conventional medical management, CMM). I am of the opinion that we should think about administering ITB therapySM in time. I think some patients could be treated earlier with greater efficiency. I expect that the new data, upon publication, will result in a revision of the medical guidelines."
Which symptoms will be decreased by ITB therapySM after stroke?
"With ITB therapySM, the muscle tone and the pain induced by the spasticity can be decreased. I have seen very good results leading into a muscle tone reduction: from the modified Ashworth scale, the value 4 to 0 (scale goes from 0 to 4, while 0 is no spasticity and 4 is severe spasticity). On top of this, the pain will be decreased substantially.
These effects are very meaningful for the patient. The patient might be able to use their arm, hold objects or walk without aid. The patient may develop better body posture which, in turn, lowers stigmatisation."
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