Less Is More; Late Recovery Unmasked By Low Dose ITB.

Wednesday, November 9, 2022

10:17 AM – 10:22 AM

Location: Station 10

Presenting Author(s)

Chittaranjan Patel (he/him/his)

Medical Graduate
PAM Rehabilitation Hospital
Dover, Delaware, United States

Non-presenting Author(s)

Craig DiTommaso, MD

Director of Early Career Physician Development
US Physiatry
Humble, Texas, United States

Research Objectives: To illustrate the role of reducing the dose of intrathecal Baclofen for long term spasticity management in a case of brain injury, with improvement in functional status without adverse effects.

Design: Single Subject Case Report

Setting: Inpatient Rehabilitation Hospital,

Participants: A thirty year old female, s/p brain injury sustained during an intracranial interventional procedure for an vascular malformation. Quadriparetic since past 4 years. No movement of lower limbs, no truncal control, fully dependent for ADL's.

Interventions: Lower dose of the intrathecal baclofen, showed better control of the trunk, and improved motor power in left lower limb. Resuming the same dose of ITB therapy after refilling the pump led to loss of the gains. Thereafter it was decided to gradually and sequentially reduce the dose of the intrathecal baclofen while monitoring the patient in an inpatient rehabilitation setting.

Main Outcome Measures: Power in lower limbs , as assessed by the MRC scale, improvement in truncal control, spasticity of limbs as assessed by care-givers.

Results: The patient who was on intrathecal baclofen for 4 years, showed improved voluntary motor control and truncal stability when the dose of ITB was reduced incidentally. The recovery was not accompanied by any withdrawal symptoms or any known adverse events. Refilling the baclofen pump and resuming the previous dose, led to return to the previous state of dependence. A decision was made to gradually reduce the dose of baclofen and this was carried out under supervision at an in-patient setting. With slow steady down-titration of the dosage (a 10% reduction in daily dose was done, every few weeks guided by clincal judgment), her strength and truncal stability improved. The patient regained some ability to control her lower extremities and was able to sit unsupported.

Conclusions: This case highlights the need to reassess dosing of baclofen in brain injury cases who are on long term therapy. Lesser dose of baclofen may be required after a few years, possibly due to some recovery in the underlying condition or due to unexplained neuroplasticity.

Author(s) Disclosures: None

Learning Objectives:

The case report demonstrates the voluntary motor movement masking properties of intrathecal baclofen.
The report focuses on the need to reassess the dosing strategies of ITB in long term treatment of spasticity of cerebral origin.
The case report suggests that a lower dose of intrathecal baclofen can be as effective in managing spasticity of cerebral origin and allowing volitional body control at the same time.