Best Practices for Intrathecal Baclofen Therapy: Troubleshooting.

INTRODUCTION: Troubleshooting helps optimize intrathecal baclofen (ITB) therapy in cases of underdose, overdose, and infection. METHODS: An expert panel of 21 multidisciplinary physicians currently managing >3200 ITB patients was convened, and using standard methodologies for guideline development, created an organized approach to troubleshooting ITB. They conducted a structured literature search that identified 263 peer-reviewed papers, and used results from an online survey of 42 physicians currently managing at least 25 ITB patients each. RESULTS: The panel developed two algorithms. The first was for loss-of-efficacy and applies to patients with previously well-controlled hypertonia on a stable dosing regimen who have increased spasticity Evaluation includes a targeted history (onset, duration, course, exacerbating/relieving factors, medications, recent procedures), physical examination (neuromuscular, vital signs, mental status), radiologic/laboratory testing (catheter imaging, noxious stimuli, infection, rising CK levels), and pump telemetry (pump interrogation, reservoir volume). Rapidly progressing hypertonia with autonomic instability or hypotonia and somnolence require emergent care and perhaps hospitalization. The second algorithm was for emergent care and describes treatment of overdose or withdrawal, which requires immediate care in a monitored setting and restoration of ITB delivery. The previous dosing schedule can be used in withdrawal of short duration; 10-20 mg every six hours can be used in longer-duration withdrawal. Supportive care includes maintenance of airway, respiration, and circulation. Seizure prevention should be considered, along with pump reprogramming or interruption, cerebrospinal fluid drainage, and sequential lumbar punctures/drains. Physostigmine and flumazenil are not usually advised. Superficial infections can be treated with oral antibiotics, and deep infections with broad-spectrum IV antibiotics (e.g., cefazolin, clindamycin, vancomycin). Explantation is often required. A new pump can be implanted in a new site under IV antibiotic coverage. CONCLUSIONS: Orderly troubleshooting helps ensure patient safety.

Treatment of vertical heterophoria ameliorates persistent post-concussive symptoms: A retrospective analysis utilizing a multi-faceted assessment battery.

PRIMARY OBJECTIVE: To examine the effectiveness of neutralizing prismatic lenses for reduction of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and vertical heterophoria (VH). BACKGROUND: Approximately 5-10% of patients with traumatic brain injury (TBI) develop persistent post-concussive symptoms. Many rehabilitation/treatment modalities are tried, but are largely unsuccessful, indicating a need for more effective treatment. DESIGN AND METHOD: This retrospective study included 38 patients with persistent post-concussive symptoms, who were diagnosed by an optometric binocular vision sub-specialist with VH (a sub-set of binocular vision dysfunction [BVD] that manifests as vertical eye and image misalignment). Data was collected both before and after prism application and included validated survey instruments for headache, dizziness, anxiety and BVD symptom burden; subjective rating (0-10 scale) of headache, dizziness and anxiety severity; and a sub-analysis of the BVD survey instrument questions that pertain specifically to headache, dizziness and anxiety. Upon conclusion of treatment, subjective assessment of overall improvement of heterophoria symptoms was obtained utilizing a 10 cm visual analogue scale. OUTCOMES: Results demonstrated marked reduction in all measures of headache, dizziness and anxiety (19.1-60.8%) and an overall subjective improvement of VH symptoms of 80.2%. CONCLUSIONS: Neutralizing prismatic lenses are an effective treatment of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and VH.

Identification of binocular vision dysfunction (vertical heterophoria) in traumatic brain injury patients and effects of individualized prismatic spectacle lenses in the treatment of postconcussive symptoms: a retrospective analysis.

OBJECTIVE: To identify a form of binocular vision dysfunction (vertical heterophoria) in a traumatic brain injury (TBI) population and to assess the effect of individualized prismatic spectacle lenses on postconcussive symptoms. DESIGN: Retrospective study. SETTING: Private physical medicine and rehabilitation practice and private optometric practice. PATIENTS: A subset of TBI patients who were initially evaluated by a single physiatrist and who received standard treatments and medications yet had persistent postconcussive symptoms. These patients were then assessed by a single optometrist, and those found to have vertical heterophoria were treated with individualized prismatic spectacle lenses. A total of 83 patients were referred for testing; 77 were positive for vertical heterophoria on screening, of which 43 had complete data sets and were included for analysis. INTERVENTIONS: All patients were treated with individualized prismatic spectacle lenses to correct for vertical heterophoria. MAIN OUTCOME MEASURES: Outcomes were measured by the difference in score before and after intervention of an objective, self-administered vertical heterophoria symptom burden instrument (Vertical Heterophoria Symptom Questionnaire [VHS-Q], presently undergoing validation) and by subjective improvement in symptoms as expressed by the patient at the end of intervention. RESULTS: There was a 71.8% decrease in subjective symptom burden when compared with preintervention baseline. There was a mean 16.7 point absolute reduction in the VHS-Q score on a 75-point scale, which represents a relative reduction in VHS-Q score of 48.1%. CONCLUSION: Vertical heterophoria was identified in a group of TBI patients with postconcussive symptoms and treatment of the vertical heterophoria with individualized prismatic spectacle lenses resulted in a 71.8% decrease in subjective symptom burden and a relative reduction in VHS-Q score of 48.1%. It appears that vertical heterophoria can be acquired from TBI.

Impairment, activity, participation, life satisfaction, and survival in persons with locked-in syndrome for over a decade: follow-up on a previously reported cohort.

OBJECTIVE: To determine the long-term outcome of patients with stable locked-in syndrome. SETTING: The community. DESIGN: Retrospective phone survey. This study was further follow-up on a previously reported cohort. PARTICIPANTS: Twenty-nine persons with locked-in syndrome were included in an initial cohort 11 years prior to the current study. Records or contact with family showed that 16 were deceased. Telephone interviews were made with 1 living patient and the caregivers of 11 others. Public records documented survival of 1 nonrespondent. OUTCOME MEASURES: Survival, codified responses regarding functional activities, social activities, and satisfaction with life. RESULTS: Five-, 10-, and 20-year survival were 83%, 83%, and 40%, respectively. Ten subjects had not been hospitalized in the previous year. Eight lived with family. Little change in impairment occurred, but care was simplified. Improvements in communication related to technology, including computer and Internet access. Eleven left home at least monthly. Caregivers reported seven expressed satisfaction with life; five were occasionally depressed. No deaths could be attributed to euthanasia and no survivor had a "no code" status. One patient wished to die, seven had never considered euthanasia, six had considered and rejected it. CONCLUSIONS: Persons with initially stable locked-in syndrome can have prolonged survival, can live in the community if there is enough support, and have some measure of quality of life.