Severe Spasticity Research Articles

Bilateral slipped capital femoral epiphysis in a cerebral palsy patient: a Case Report

BackgroundSlipped capital femoral epiphysis (SCFE) is usually seen in patients with high body mass index (BMI) and endocrine diseases. SCFE is exceedingly rare among Cerebral palsy (CP) patients due to spasticity present in those patients. Percutaneous in situ fixation is the treatment option for SCFE patients. According to the literature, there’s no single case report with SCFE in a spastic CP patient with no prior history of trauma, seizure episodes, or endocrine disease.Case presentationWe report a case of an 11-year-old spastic cerebral palsy (CP) patient with a physical status of level 5 motor function on the gross motor function classification system. He was brought by his mother to the clinic complaining of bilateral hip pain. The mother denied any history of trauma or any seizure episodes. The pain had started spontaneously. Physical examination showed severe spasticity and bilateral hip abduction with external rotation. Drehmann’s sign was positive. Bilateral hip radiographs revealed bilateral partial open femoral capital physis with evidence of SCFE bilaterally. Also, the Southwick angle was measured, and it was severe. The patient was taken to the operating room and treated with closed reduction and percutaneous in situ fixation. He was seen multiple times following surgical intervention, reporting pain relief, and showing complete wound healing.ConclusionThis report concludes that paraplegic spastic CP patients may present with SCFE spontaneously without trauma, seizures, or an underlying endocrine disease. Also, severe spasticity might potentially be a risk factor for SCFE, although further investigations would be necessary to establish a conclusive link.

The p.D417N variant of TUBB4A as a possible cause of hereditary spastic paraplegia: a case report

BackgroundTubulins are dimeric proteins expressed in all eukaryotic cells, serving as the fundamental building blocks of microtubule filaments. The TUBB4A gene encodes the protein β-tubulin. Mutations of TUBB4A have been associated with two neurodegenerative diseases with very different clinical characteristics: dystonia type 4 (DYT4) and Hypomyelination with Atrophy of the Basal Ganglia and Cerebellum (H-ABC). Several cases of patients with H-ABC or unclassified leukoencephalopathy show spastic ataxia with or without leukodystrophy in association with mutations in exon 5 of TUBB4A gene.Case presentationWe report the case of a 65-year-old woman who has been complaining of progressive difficulty in walking since childhood. The neurological examination revealed, among all, a spastic gait, difficulties in standing on the toes and heels, brisk deep tendon reflexes at upper limbs, clonic patellar reflexes, brisk ankle reflexes, as well as bilateral Babinski and Hoffmann sign, brisk jaw jerk and severe lower limb spasticity. NGS studies for inherited cases of spastic paraplegia revealed a novel variant of unknown significance (VUS) (c.1249A > G, p.D417N), in TUBB4A. To the best of our knowledge, this variant has not been reported in the literature or any databases in association with these diseases.ConclusionWe report the case of a patient carrying a variant of uncertain significance (VUS) of the TUBB4A gene, showing a progressive, spastic paraparesis, supporting the extension of the phenotypic spectrum up to include spastic paraplegia.

Replacing hospital nurse consultations with home-based nurse consultations for severe spasticity patients on intrathecal baclofen: a qualitative study

Aim This qualitative study explored the experiences of patients, caregivers and healthcare professionals after replacing hospital consultations with a home service solution for patients treated for severe spasticity with intrathecal baclofen. Method Semi-structured interviews were conducted with six patients, six caregivers and six healthcare professionals. The data were analysed using interpretative phenomenological analysis. Results Four themes were identified: 1) Caregivers’ new role and contribution to treatment, 2) Hospital consultations in home settings changed the balance of power, 3) A compassionate relationship, and 4) Contextual care for patients. Conclusion The home-based consultations improved caregivers’ understanding of the treatment and helped them to become active spokespersons for the patient by contributing important information about the patient’s perspectives and the effects of the treatment. The balance of power shifted towards a more equitable dynamic between patients and nurses during home consultations, facilitated by greater involvement of the patient perspective. The nurses’ working conditions changed, but patients and caregivers appreciated the shift in treatment setting.

Whiteness, redness, blueness and greenness profile assessment and design of experiments approach to microwave-aided sensitive and green spectrofluorophotometric determination of baclofen.

As a gamma amino butyric acid-ergic agonist, Baclofen is often prescribed to adults and children for the treatment of severe spasticity that originates in the brain or spinal cord. Even after reviewing the literature extensively, no one has documented a method for estimating baclofen using microwave-assisted stability-indicating spectrofluorimetric techniques, despite the abundance of options for baclofen stability, assay, and bioanalysis. Organic solvents, which are typically necessary for current procedures but may be costly and toxic, have a severe effect on aquatic life and the environment. Using green solvents and 4-chloro-7-nitrobezofuran as a fluorescent probe, this work conducted a stability-indicating spectrofluorimetric estimate of baclofen. Through the use of a design-of-experiments technique, a reliable microwave-aided spectrofluorimetric method was developed, with little solvent consumption and time for sample analysis. Prior to conducting response surface analysis and optimizing important variables and responses, a fractional factorial design was used to screen method variables and responses. A central composite design was then employed for these purposes. This flexible spectrofluorimetric technique was used to assess baclofen concentrations in forced degraded samples and marketed formulations. For baclofen determination, the suggested spectrofluorimetric approach was found to be green, quick, easy to use, economical, and user-friendly.

Living With Spasticity During the COVID‐19 Pandemic: A Qualitative Study of Patient, Carer and Physician Experiences

ABSTRACTBackgroundApproximately 4.4 million people in England (8% of the total population) are living with a long‐term neurological condition. Within this group of vulnerable individuals, there will be individuals living with severe spasticity that requires regular outpatient treatment with botulinum toxin injection. The closure of outpatient spasticity services during the pandemic impacted individuals who required spasticity treatment and their carers, as well as the specialist clinicians responsible for service delivery.ObjectivesWe aimed to gain insight into the experiences of individuals living with spasticity, their carers and a clinical spasticity service lead during the pandemic, and to reflect on potential learning for the future.MethodsA qualitative study was designed using semi‐structured interviews conducted by telephone. Participants comprised patients living with a long‐term neurological condition who attended outpatient spasticity clinics before the start of the pandemic in England, primary carers who accompanied patients attending these clinics and a clinical spasticity service lead. Data were audio recorded, transcribed, anonymised and coded. Data analysis utilised the One Sheet of Paper thematic approach to identify themes, which were discussed and analysed by the interdisciplinary research team and two patient and carer participants.ResultsOut of the 11 participants recruited, aged 36–77 years, seven comprised people living with spasticity related to a long‐term neurological condition, three were carers and one was a clinical spasticity service lead. Six participants were male and five were female. Among the participants, four were stroke survivors, two were living with spinal cord injury and one was living with multiple sclerosis. Analysis revealed six major themes: experience of living with spasticity during the pandemic; impact of the pandemic on patient, carer and clinician health; access to and experience of outpatient clinic appointments; coping strategies during the pandemic; system improvements; and learning from the pandemic period.ConclusionThese findings contribute research knowledge to a very limited research knowledge base and suggest that there is scope for improving system and service delivery through the allocation of research funding to senior clinicians working in this specialist area.

Peritoneal baclofen pump migration: a rare complication of subfascial placement. Illustrative cases.

The intrathecal baclofen pump is an effective treatment option for patients with severe spasticity. In children, subfascial pump placement is often preferred given concerns for infection and wound healing. However, this approach is not without risk, and rare complications, such as peritoneal pump migration, can occur. The authors describe three pediatric cases of peritoneal pump migration at their institution over the past 14 years (3/545, 0.5%). All three patients had low body weight (below the 39th percentile), and two had scoliosis requiring surgery. All pumps had been placed using the subfascial technique. The first case occurred 6 months postplacement, and the pump was not replaced. Cases 2 and 3 occurred at 2 and 3 years postplacement, respectively, and both pumps were replaced. The authors conclude that peritoneal pump migration, although uncommon, can occur in patients with subfascial pump placement, and providers should have a low threshold of suspicion for repeat imaging prior to refilling if the pump's location has migrated. Potential contributing factors to pump migration include a patient's small size, a larger pump size (40-mL pump), and scoliosis. All these factors should be considered during pump placement, and surgeons can consider using a 20-ml pump for smaller patients. https://thejns.org/doi/abs/10.3171/CASE24290.

Effective management of hip adductor spasticity: A case report on diagnostic obturator nerve block and botulinum toxin injection

It is important to distinguish spasticity from contracture in patients presenting with upper motor neuron (UMN) syndrome and restricted range of movement (ROM) because treatment strategies differ. We demonstrate how we perform ultrasound-guided obturator nerve (ON) block to distinguish spasticity from contracture in a patient with bilateral hip adductor spasticity secondary to a non-traumatic spinal cord injury. We report here a 26-year-old gentleman with a history of Mycobacterium tuberculosis thoracic spondylodiscitis with spinal cord compression. His neurological status was T6 ASIA impairment scale C and his impairments were spastic paraparesis, neurogenic bowel and neurogenic bladder. He had difficulty with wheelchair transfer and positioning, perineal care as well as intermittent self- catheterization due to severe spasticity of bilateral hip adductors with significantly restricted ROM. Bilateral ON block resulted in clinically significant improvement in spasticity and ROM of the right lower limb but not the left. The effects were similar following intramuscular BTX-A injection of bilateral hip adductors. Ultrasound-guided diagnostic ON block via the distal approach is inexpensive, safe and can be readily performed in clinic setting without the need for sedation or prolonged monitoring. Improvement in MAS score of at least 1 point and ROM of at least 15° following ON block should be used to distinguish hip adductor spasticity from contracture in patients with UMN syndrome and reduced ROM. Diagnostic nerve block allows for greater physician certainty when discussing various treatment options including expedited referral for surgical consult. The findings of this report offer insights into the decision-making process in managing complex presentations of UMN syndrome.

Efficacy of Dry Needling in Enhancing Hand Function and Reducing Spasticity in MCA Stroke Patients: A Prospective Case Report

Stroke, particularly involving the middle cerebral artery (MCA), often leads to persistent disability, significantly impairing hand function and inducing severe spasticity in the forearm flexors due to complex motor pathway involvement. This case report evaluates the effectiveness of combining dry needling therapy (DNT) with task-oriented training (TOT) in reducing spasticity and improving hand function in a post-MCA stroke patient. A 61-year-old male with right-side hemiplegia following a left MCA stroke, compounded by a history of diabetes, hypertension, and recent kidney stone diagnosis, participated in this study. The patient experienced severe functional limitations due to spasticity (grade 3 on the Modified Ashworth Scale) and scored 31 on the CAHAI-13, indicating significant hand dysfunction. DNT was applied to key forearm muscles (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, and pronator teres), followed by TOT targeting daily tasks. Post-intervention, the patient demonstrated significant improvements: spasticity was reduced (Modified Ashworth Scale score decreased from grade 3 to grade 2), and muscle hypertonicity, as measured by EMG, was reduced in all targeted muscles. Functional hand use improved markedly, with the CAHAI-13 score increasing from 31 to 45. These improvements led to enhanced independence in daily activities. This case report highlights the clinical relevance of integrating DNT with TOT in stroke rehabilitation. The combined intervention not only reduced spasticity and improved neuromuscular function but also led to meaningful gains in hand function, enhancing the patient’s ability to perform daily activities independently. Given the promising results, this combined approach could serve as a practical and effective strategy for improving motor recovery and functional independence in post-stroke patients. Further studies with larger sample sizes are necessary to confirm these findings and explore the broader application of this approach in clinical practice.

THE EVALUATION OF TOTAL HIP ARTHROPLASTY IN THE MANAGEMENT OF SPASTIC PAINFUL HIP DISLOCATION IN CEREBRAL PALSY

Spasticity used to be considered a contraindication for total hip replacement (THR) procedures. Due to the development of implants as well as surgical skills, THR became an option for the treatment of painful dislocation of the hip joint in patients with spastic plegia. The aim of this study was an evaluation of mid-term results of THR in spastic CP adolescent patients with painful hips with hip joint subluxation or dislocation.In 2014–2022, 18 pts (19 hips) with CP aged 16 to 20 years underwent THR in our department. The mean follow-up was 4 years (range: 1 – 9 years). Results were evaluated using the Gross Motor Function Scale, VAS scale in accordance with the Ashworth scale, types of implants used (dual mobility cup and not dual mobility cup), and radiological assessment (Crowe scale). Complications have been thoroughly analyzed.In 10 pts there has been an improvement in the GMFSC scale average from 1 to 2 points observed after the surgery. All pts have improved in the VAS scale average of 8 points (from 10 to 7). According to the Crowe scale repositioning of preoperative dislocation to primary acetabulum was achieved in all cases. Complications occurred in 4 cases: dislocations of 2 THR with dual mobility cup and 2 THR with non-dual mobility cup requiring revision surgery with good final result. No statistical significance was noted according to the type of cup (Mann-Whitney U Test).The most important risk factor for complications is severe spasticity. We believe, that CP pts with painful hips should be treated using THR. We didn't observe any significant differences between the types of implants.These findings may serve as a basis for the prediction of outcomes of THR treatment in this specific group of pts.Level of evidence: Case-control or retrospective comparative study-Level III

Intrathecal Baclofen Infusion-Botulinum Toxin Combined Treatment Efficacy in the Management of Spasticity due to Cerebral Palsy.

Cerebral Palsy (CP) is a group of permanent, but not unchanging, disorders of movement and/or posture and motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain. One clinical presentation is muscle spasticity, which leads to a significant impact on the individual's functionality and quality of life. Spasticity treatment is multidisciplinary and includes pharmacological and physical intervention; intrathecal baclofen shows a positive effect in severe spasticity and suboptimal response to oral drugs, while local injection of Botulinum toxin type A (BTXA) improves muscle tone, motion and pain. The aim of this study was to evaluate the efficacy of the combined intrathecal baclofen infusion (ITB) - botulinum toxin treatment in the management of spasticity in CP. 8 patients with spastic tetraparesis were enrolled. All patients were treated with intrathecal Baclofen; in lower limbs, no spastic symptoms appeared, while marked spasticity was noted in upper limbs. We injected the right and left Biceps Brachial (BB) and Flexor Digitorum Superficialis (FDS) muscles with botulinum toxin type A. All patients underwent Myometric measurement, Ashworth Scale, Numerical Rating Scale, and Visual Analogic Scale evaluation before infiltration (T0), 30 days after injection (T1), 60 days after injection (T2), and 90 days after treatment (T3). All data demonstrated an improvement in spasticity, pain, quality of life, and self-care during the study, with p < 0.05. No side effects appeared. This study demonstrated the efficacy and safety of intrathecal baclofen infusion and botulinum toxin combined treatment in the management of spasticity, pain, quality of life, and selfcare in CP patients.

Development of a home visit solution with a route- and appointment planning tool for patients with severe spasticity: A participatory design study.

Objectives: This article describes how a home visit solution was developed in a co-design process between patients in treatment for severe spasticity, their caregivers and hospital nurses. The solution was developed using a participatory design approach and was based on the identified needs of the participants. Methods: We developed a home visit solution through an iterative process and a collective 'reflection-in-action' approach with patients, caregivers and healthcare professionals. Results: The study revealed the complexities of establishing new routines around home visits. The solution included a new workflow for the nurses and a new route and appointment planning tool. Conclusion: Through a participatory design approach, the users developed a home visit solution that minimised disruption to patients' daily lives and facilitated a dialogue between the nurses and the caregivers about the treatment and the patients' spasticity, which helped to adjust the treatment in line with the patient´s needs.

Poststroke Spasticity: Pathophysiology and Management An Accurate Evaluation of Spasticity

Stroke is a major contributor to long-term impairment and disability, affecting up to one-third of survivors and almost half of patients showing neurological deficit at six months. Spasticity affects approximately 25% of individuals within two weeks of a stroke and increases to 44% in patients who have had a second stroke. Severe or incapacitating spasticity affects 15% of post-stroke individuals. Poststroke spasticity is also linked to additional signs and symptoms of the upper motor neuron syndrome, such as simultaneous contraction of agonist and antagonist muscles, weakness of the muscles, and a lack of coordination. Spasticity arises due to aberrant neuroplasticity that develops after a stroke and there is currently no specific intervention method designed to address and correct this abnormal plasticity that takes place during the acute phase. Just before implementing any measures to deal with spasticity, it is crucial to evaluate the influence on the quality of life and level of severity. Several grading scales are used to measure spasticity such as the MAS and modified Tardieu scale.There are various therapeutic approaches that may be categorized into three main classes: physical, pharmaceutical, and surgical. Each class has a distinct purpose and is used at the appropriate moment to reduce the level of spasticity and improve the patient's health. Physiotherapy serves as a base of improving the patient's condition and facilitating the development of brain networks. The objective of post stroke spasticity management must include not only the reduction of muscle hypertonia, but also the evaluation of how post stroke influences functionality and overall mental health. Improper treatment or non-compliance may result in increased pain, joint contraction, and further disability. The goal is to assist the patient in achieving the best possible quality of life. Keywords: Pathophysiology of Post-Stroke Spasticity; Management of Post-Stroke Spasticity; Evaluation of Post-Stroke Spasticity

Safety and effectiveness of thermal radiofrequency applied to the musculocutaneous nerve for patients with spasticity.

Evaluate safety and effectiveness of thermal radiofrequency in the musculocutaneous nerve in patients with focal elbow flexor spasticity. Ambispective observational follow-up study. Patients with focal spasticity secondary to central nervous system injury with elbow flexor pattern who received thermal radiofrequency treatment in the musculocutaneous nerve between 2021 and 2023 were included. 12 patients. Ultrasound-guided thermal radiofrequency was applied to the musculocutaneous nerve at 80°C for 90 s. Effectiveness was assessed prior to thermal radiofrequency and at 6 months using scales to measure pain (VAS), spasticity (MAS), disability (DAS), quality of life (SQol-6D), patient-perceived and physician-perceived satisfaction (PIG-C, PGA), and goal attainment (GAS). Elbow joint range of motion was evaluated via goniometry. Safety was evaluated by assessing side effects. Patients had statistically significant improvements in spasticity (p = 0.003), severe elbow flexion (p = 0.02), pain (p = 0.046), functioning (p < 0.05), and spasticity-related quality of life (p < 0.05 in three sections). Furthermore, treatment goals were attained. Patient- and physician-perceived clinical improvement was achieved. Regarding side effects, two patients had dysesthesia that was self-limiting, with maximum duration of 1 month. Thermal radiofrequency in the musculocutaneous nerve can be a safe, effective treatment for patients with severe spasticity with an elbow flexor pattern.

Categorizing knee hyperextension patterns in hemiparetic gait and examining associated impairments in patients with chronic stroke

BackgroundPost-stroke hemiparetic gait exhibits considerable variations in motion patterns and abnormal muscle activities, notably knee hyperextension during the stance phase. Existing studies have primarily concentrated on its joint angle or moment. However, the underlying causes remain unclear. Thus, the causes of knee hyperextension were explored from a new perspective based on temporal-durational factors. Research QuestionDoes the temporal-durational difference of knee hyperextension presence result from specific decreased motor functions? MethodsBarefoot gait at a comfortable speed was captured using a three-dimensional camera system. Scores of knee hyperextension used a metric with the temporal-durational factor of knee hyperextension presence in each of four stance phases (1st double support, DS1; early single-leg stance, ESS; late single-leg stance, LSS; 2nd double support, DS2). These scores were used in cluster analysis. The classification and regression tree analysis characterizing each knee hyperextension cluster used the clinical measures of the lower limb and trunk motor function, muscle strength, and spasticity as explanatory variables. ResultsThirty patients with hemiparetic chronic stroke who exhibited knee hyperextension during gait were included. Four knee hyperextension clusters were shown: Momentary (almost no hyperextension), Continuous (DS1–DS2), ESS–LSS, and ESS–DS2. Knee flexor strength was lower in the groups with long hyperextension durations (Continuous and ESS–DS2) compared with short durations (ESS–LSS and Momentary). ESS–DS2 exhibited higher trunk motor function than Continuous, whereas more severe spasticity was observed in ESS–LSS than in Momentary. SignificanceThis study successfully classified four hemiparetic gait patterns with knee hyperextension based on the temporal-durational factor, providing valuable perspectives for understanding and addressing specific functional physical impairments. These findings offer guidance for focusing on related physical functions when striving for gait improvement with knee hyperextension and are expected to serve as a reference for treatment decision-making.

Long-term use of intrathecal baclofen reduces neuropathic pain and its interference with general activity in spinal cord injury individuals.

Long-term analgesic effect of intrathecal baclofen was reported in individuals with spinal cord injury. We conducted a prospective study to evaluate the effect of intrathecal baclofen on subtypes of neuropathic pain and its interference with general activity. Nine spinal cord injury individuals who presented with severe spasticity and moderate to severe neuropathic pain received intrathecal baclofen via an implanted pump. We applied the ASIA Impairment Scale to assess spinal cord injury severity. Neuropathic pain was evaluated by numerical rating scale, Neuropathic Pain Symptom Inventory, and Brief Pain Inventory. Evaluations were performed at baseline and after at least 6months of continuous intrathecal baclofen treatment. Intrathecal baclofen led to significant pain reduction as measured by numerical rating scale, Neuropathic Pain Symptom Inventory, and Brief Pain Inventory (p < 0.05). Improvements were significant for paroxysmal pain and dysesthesia and for pain interference with general activity, as assessed by the Brief Pain Inventory (p < 0.05). There was a significant relationship between the time since spinal cord injury and changes in paroxysmal pain as well as in the total Neuropathic Pain Symptom Inventory score (p < 0.05). The baclofen dose correlated also to the percentage changes in neuropathic pain improvement and sleep (p < 0.003). The present results provide evidence that intrathecal baclofen effectively reduces neuropathic pain, particularly paroxysmal pain and dysesthesia, and improves pain interference and overall well-being in individuals with spinal cord injury. Clinicians should be aware of this less well-known beneficial effect of intrathecal baclofen and should consider such a treatment option for better control of neuropathic pain in individuals with spinal cord injury.

Effectiveness, Safety and Patients' Satisfaction of Nabiximols (Sativex®) on Multiple Sclerosis Spasticity and Related Symptoms in a Swiss Multicenter Study.

Background: Cannabinoid oro-mucosal spray nabiximols is approved for patients with moderate to severe multiple sclerosis spasticity (MSS) resistant to other antispastic medications. Few real-world data are available on the effectiveness, safety and patients' satisfaction in MS patients treated with nabiximols as monotherapy. Methods: To investigate the effectiveness, tolerability and satisfaction of nabiximols in a real-life multicentric Swiss cohort as monotherapy or with stable doses of other antispastic medications, and explore clinical features which may predict treatment response. The following data were collected at treatment start (baseline) and 12 weeks thereafter: Modified Ashworth scale (MAS), scores at numerical rating scales ranging from 0 (absent) to 10 (considerable) for effect on spasticity (sNRS), pain (pNRS), gait (gNRS), urinary symptoms (uNRS), tolerability (tNRS) as assessed by the treating neurologist, and overall treatment satisfaction (TsNRS) and tolerability (tNRS) as assessed by the patient. Results: Ninety-five patients (44 relapsing remitting, 37 secondary progressive and 14 primary progressive MS; median age = 53 (IQR 45-62); female 70%; median EDSS 6 (IQR 4-6), concomitant antispastic treatments in 54% of patients) were included. From baseline to week 12, median MAS score decreased from 3.0 to 2.0 (p < 0.001). Median scores of the each NRS also significantly decreased (p < 0.001 for all comparisons). At week 12, the median TsNRS and tTS scores were 8/10 (IQR: 6-9) and 9/10 (IQR: 7-10), respectively, and 93.7% of patients continued to use nabiximols at the average dose of six sprays/day. No clinical factors, including use of nabiximols as add on vs. monotherapy, were associated with responder status. Conclusions: Our first Swiss, multicentric, observational, real-life study supports and enhances previous finding of nabiximols as monotherapy and as add-on therapy, being an effective, safe and well-tolerated treatment option for resistant MS spasticity and spasticity-related symptoms (pain, bladder dysfunction and gait).

Untreated Moderate-to-severe Sleep Apnea Is Associated with More Severe Spasticity in Individuals Living with Spinal Cord Injury: A Cross-sectional Prospective Study. (P7-11.013)

Untreated Moderate-to-severe Sleep Apnea Is Associated with More Severe Spasticity in Individuals Living with Spinal Cord Injury: A Cross-sectional Prospective Study. (P7-11.013)

Botulinum toxin A injection for post-stroke upper limb spasticity and rehabilitation practices from centers across Asian countries.

Describe real-life practice and outcomes in the management of post-stroke upper limb spasticity with botulinum toxin A (BoNT-A) in Asian settings. Subgroup analysis of a prospective, observational study (NCT01020500) of adult patients (≥18 years) with post-stroke upper limb spasticity presenting for routine spasticity management, including treatment with BoNT-A. The primary outcome was goal attainment as assessed using goal-attainment scaling (GAS). Patients baseline clinical characteristics and BoNT-A injection parameters are also described. Overall, 51 patients from Asia were enrolled. Rates of comorbid cognitive and emotional problems were relatively low. Patients tended to have more severe distal limb spasticity and to prioritize active over passive function goals. Most (94.1%) patients in the subgroup were treated with abobotulinumtoxinA. For these patients, the median total dose was 500 units, and the most frequently injected muscles were the biceps brachii (83.3%), flexor carpi radialis (72.9%), and flexor digitorum profundus (66.7%). Overall, 74.5% achieved their primary goal and the mean GAS T score after one treatment cycle was 56.0 ± 13.0, with a change from baseline of 20.9 ± 14.3 (p < 0.001). The majority (96.1%) of Asian patients were rated as having improved. In the Asian treatment setting, BoNT-A demonstrated a clinically significant effect on goal attainment for the real-life management of upper limb spasticity following stroke.

Utilizing combination intrathecal baclofen and analgesic medication to manage spasticity and pain in patients with pediatric-onset disability: Case series.

The use of intrathecal medications for the management of spasticity and various pain syndromes in the adult population has been previously reported. However, no evidence-based guidelines currently exist in the pediatric population. This case series presents patients (n = 8) with pediatric-onset disability who underwent placement of intrathecal baclofen pumps initially for management of severe spasticity. Despite titration of dose and use of oral analgesia, their uncontrolled pain persisted. Each patient was transitioned to a combination of baclofen and analgesic intrathecal therapy. The outcome in pain improvement and quality of life, as reported by patients and/or caregivers, were retrospectively reviewed. Retrospective review of the background and decision-making process regarding transition to combination intrathecal therapy identified patient selection characteristics. Each patient and/or their caregivers completed a survey regarding improvements in pain, spasticity, function, and quality of life following initiation of combination intrathecal medications. Survey results revealed improvements in functional and pain assessments after initiation of combination baclofen and analgesic intrathecal medication. Patients and caregivers reported decreases in pain and oral spasticity medications. Use of pumps with antispasmodic and analgesic medication for combination intrathecal medication delivery should be considered in the management of patients with childhood-onset disabilities who have both severe spasticity and pain.

Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique".

Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers. Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump. Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications. The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.