Baclofen

Herman et al. 1992
USA
PEDro=8
RCT & Non RCT
N=7

Population: Age = 33-63 yrs; Gender: males = 3, females = 6; Diagnosis: MS=4, TMy=2, SCI=2, Epidural absess=1; Spasm related pain (SRP): range 1 to 10yrs; Dysesthesia: 2-4 yrs; RCT n=5/Non-RCT n=2.
Treatment: Baclofen and placebo were randomly administered into the L1-2 interspace of each subjects.
Outcomes Measures: Ashworth Scale and tendon tap; VAS for dysesthetic pain intensity; threshold/EMG relationships after controlled pinch as an indication of nociceptive pain.

• Intrathecal baclofen also significantly suppressed the dysethetic (burning quality) pain among 6 of the 7 RCT subjects (p<0.001). One of the non-RCT subjects who also noted dysesthetic pain was abolished.
• Pinch induced pain was not affected by either placebo or baclofen.

Boviatsis et al. 2005
Greece
Downs & Black score=18
Case Series
Initial N=22; Final N=21

Population: MS, SCI (N=7): Level of injury: C4 to T11. Results were presented by etiology
Treatment: Intrathecal Baclofen pump implantation. Subjects were implanted with an infusion pump delivering a continuous flow at a fixed rate of bolus intrathecal Baclofen.
Outcome Measures: Barthel index scale, Ashworth scale and Penn spasm scale, self-assessment pain scale.

• The self-assessment pain scale revealed a limited improvement in pain (p=0.0941).

Plassat et al. 2004
France
Downs & Black score=16
Case series
Initial N=41;Final N=37

Population: SCI (N=17), MS and cerebral spasticity. Spasticity of spinal cord origin, N-33)
Treatment: intrathecal Baclofen pump placement
Outcome Measures: VAS satisfaction score locomotion, pain, sleep, Ashworth.

• Of the 25/40 patients suffering pain before ITB, 80% noted 25% improvement in pain and 40% noted 30-50% improvement. Twenty percent reported no change.
• Those suffering from neuropathic pain received coadministration of morphine or clonidine.

Loubser & Akman 1996; USA
Downs & Black score=13
Pre-post
N= 16

Population: Age = 21-63 yrs; Gender: males = 15, females = 1; Severity of injury: Frankel classification: A to C; Type of pain: neurogenic=6, musculosketal=6, mixed pain=3.
Treatment: Baclofen infusion pump implantation.
Outcome Measures: Pain.

• 12 out of 16 patients described chronic pain prior to the procedure.
• No significant differences were noted between the visual analogue score (VAS) at the 6 and 12-month period following the pump implantation.
• For those with neurogenic pain symptoms, ANOVA revealed a non-significant effect of intrathecal baclofen on pain at both 6 and 12 months. (F2, 16), adjusted p=0.26.
• In 5 of 6 patients with musculoskeletal pain symptoms pain severity decreased in conjunction with control of spasticity.  Musculoskeletal pain responded to the Baclofen infusion while neurogenic pain did not.

Motor Point Phenol Block

Uchikawa et al. 2009
Japan
D&B=19
Case series
N=7

Population: Mean age=55.8yrs; Gender: males=6, females=1; Level of injury: C; Severity of injury: AIS A=2, C=1, D=4.
Treatment: A teflon coated needle and a weak electric stimulation was used to localize a motor point on the anterior surface of the scapula. Phenol was injected into the point where the strongest muscle contraction was observed. Assessments were made before and 24hrs post injection.
Outcome Measures: VAS, Ashworth scale, flexion, abduction, rotation.

• Significant improvement was seen in: passive ROM of shoulder flexion, abduction and external rotation; shoulder pain measure in the VAS (p<0.05).
• No significant improvement was seen in the modified Ashworth scale ratings and the manual muscle test ratings for flexion, abduction and external rotation.

Botulinum Toxin

Marciniak et al. 2008;
USA
Downs & Black score=12
Case series
N=28

Population: SCI: Mean age = 48 yrs; Severity of injury: AIS A = 5, B-D = 23; Cause of injury: traumatic = 3, falls = 8, gun shot wounds = 1, diving = 3, knife wound = 1, blunt trauma = 1.
Treatment: Botulinum toxin (BTX) type A injection for focal spasticity control.
Outcome Measures: Improvement in ambulation, positioning, upper-extremity function, hygiene, pain.

• Improvement was seen post-injection in:
  • Ambulation, 56%.
  • Positioning, 71%.
  • Upper-extremity function, 78%.
  • Hygiene, 66.6%.
  • Pain, 83.3%.
• The effectiveness of the BTX injections was not influenced by early use of BTX injections (less than a year after onset of symptoms) vs. late use.
• Improvement in those with upper arm compared to lower arm injections was similar. Also, level of completeness of the SCI did not effect improvement.