What is the role of intrathecal baclofen (ITB) in the treatment of spasticity?

Updated: Jun 28, 2019
  • Author: Krupa Pandey, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Lack of substantial therapeutic benefit from oral baclofen, a mainstay of drug therapy, can result from an inadequate penetration of the blood-brain barrier by the drug. Since unacceptable CNS effects often occur when high doses of baclofen are taken orally, the therapeutic effect usually cannot be improved by increasing the dose. Sedation, somnolence, ataxia, and respiratory and cardiovascular depression are the drug's CNS depressant properties.

ITB therapy consists of long-term delivery of baclofen to the intrathecal space. This treatment can be helpful for patients with severe spasticity affecting the lower extremities, particularly those patients whose conditions are not sufficiently relieved by oral baclofen and other oral medications. [41, 42]

ITB can be used to treat severe spasticity from various causes. Benefits of ITB typically include reduced tone, spasms, and pain, and increased mobility. Other benefits may include improved sleep quality, bladder control, self care, and self-image. It also may allow patients to decrease and often discontinue other spasticity medications.

ITB should be considered in patients who have disabling spasticity unresponsive to conservative pharmacotherapy or in whom therapeutic doses induce intolerable side effects. Pharmacotherapy should include, but need not be limited to, a trial of oral baclofen. The Ashworth Scale and Spasm Frequency Scale appear to be clinically useful measures of spasticity; a severity of 3 on the Ashworth and 2 on the Spasm Frequency for at least 12 months are considered reasonable criteria for ITB therapy consideration.

In a study of the long-term effects (>5 y) of ITB on impairment, disability, and quality of life in patients with severe spasticity of spinal origin, Zahavi et al found that the most prominent improvements reported by the patients were increased ease of transfer, better seating posture, ease of care in ADLs (passive), and decrease in pain. [43]

Of 21 patients treated in the study, 11 had MS, 6 had SCI, and the rest had a variety of nonprogressive spinal disorders. The mean length of treatment was 6.5 years. Significant sustained improvement was seen for spasticity and spasm score. The Expanded Disability Status Scale score worsened, as did the ambulation index and overall incapacity status scale score. No significant changes were seen on the Sickness Impact Profile or the Hopkins Symptom Checklist. No significant differences were found for any measure between patients with MS and those with static spinal disorders.

The most common complications were muscle weakness, somnolence, catheter malfunction, and surgery complications. The authors reported that all patients but 2 were satisfied with their treatment and would undergo treatment again.

A review of ITB therapy in 174 children with cerebral palsy by Borowski et al found that ITB therapy is safe and effective for severe spasticity in this population, and that patients and caregivers find it highly satisfactory, but that the technique does have a 31% rate of complications requiring surgical management over a 3-year treatment period. [44]


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