Authors (including presenting author) :
CHIN SH (1), CHEE SH (1), LUK KY (1), CHAN CM (1), YU CH (2), CHEUNG FC (2), CHAN HF (3), CHEUNG YF (3)
Affiliation :
(1) Physiotherapy Department, Queen Elizabeth Hospital, Hong Kong
(2) Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong
(3) Department of Medicine, Queen Elizabeth Hospital, Hong Kong
Introduction :
Intrathecal baclofen (ITB) therapy, which delivers baclofen into the intrathecal space by an implanted programmable pump, is one of the effective treatments to reduce spasticity. Physiotherapist is an integral part of the multidisciplinary team for patients receiving ITB therapy, from pre-surgery evaluation, to post-surgery evaluation and intensive rehabilitation.
Objectives :
To illustrate the role of physiotherapy in the ITB therapy by case study of patient with congenital spasticity.
Methodology :
Mr. N, a patient of cerebral palsy with spastic diplegia, underwent ITB pump surgery. Prior to the surgery, screening trials were conducted by neurosurgeon and neurologist to evaluate the patient’s responsiveness on ITB. Physiotherapist performed serial assessments to assist in examining the effects of ITB on his spasticity and functions, including muscle tone assessment with Modified Ashworth Scale (MAS), instrumented muscle tone assessment with MyotonPro, observational gait analysis with video taking, and functional assessments. Assessments were done before the trial, and repeated on every 2, 4 and 6 hours after baclofen injection. Throughout the process, physiotherapists provided timely motor, functional evaluation and intervention in facilitating the team in working out the treatment plan. As the ITB trial show promising results, he proceeded to the ITB pump implantation surgery.
Result & Outcome :
Mr. N lower limbs’ spasticity improved after the ITB surgery, with average MAS score one-point lower in hips and knees’ muscles, and three-point lower in ankles plantarflexors. His improvement in muscle stiffness also objectively revealed by an average 3Hz reduction in MyotonPro. However, the decrease in his muscle tone could not immediately transfer into functional gain, as he used to rely on spasticity for stability and movement. Intensive physiotherapy interventions including stretching, motor relearning, and gait training were provided twice per day during his in-patient stay to promote his functional gains, and new movement and gait pattern relearning. Continuous assessment along with close communication with neurologist were necessary for the titration of an optimal ITB dosage for treatment. After one-week intensive training, the gait pattern of Mr. N improved. He was able to walk with a quadripod independently with satisfactory stability, and his spastic scissoring gait was much improved. There was no forefoot dragging over ground during swing phase, and obviously less tip- toeing during stance phase in his gait cycle. Mr. N was discharged home with out-patient physiotherapy training. In conclusion, ITB therapy with intensive physiotherapy is crucial for improvement in motor function in patients with congenital spasticity.
