Intrathecal baclofen in multiple sclerosis and spinal cord injury: complications and long-term dosage evolution.

OBJECTIVE: To investigate the long-term dosage evolution and complication rate of intrathecal baclofen use in multiple sclerosis and spinal cord injury patients, based on a large population with a long follow-up. DESIGN: Retrospective data analysis. SETTING: Academic hospital. SUBJECTS: Patients with multiple sclerosis (n = 81) or spinal cord injury (n = 49) having an intrathecal baclofen pump implanted at the University Hospitals Leuven between 1988 and 2009. INTERVENTION: Medical records review of included patients in August 2010. MAIN MEASURES: Complications linked to intrathecal baclofen therapy. Daily baclofen dosage after 3 and 6 months, and yearly thereafter. Data on dosage evolution were analysed using a mixed-effect linear model. RESULTS: In 130 patients with a mean follow-up of 63 months, comprising 797 pump years, 104 complications were recorded. This corresponds to a complication rate of 0.011 per month, equally divided among both groups. Seventy-eight of these complications were catheter related. The mean dosage of baclofen stabilizes two years after implantation at 323 µg/day in the multiple sclerosis population. In spinal cord injury patients the daily dose only stabilizes after five years at a significantly higher dosage (504 µg/day). No significant increase in dosage is seen in the long term. CONCLUSIONS: In multiple sclerosis and spinal cord injury patients, intrathecal baclofen therapy has a complication rate of 1% per month. Complications are mainly due to catheter-related problems (74%). The intrathecal baclofen dosage stabilizes in the long term, indicating that long-term tolerance, defined as progressive diminution of the susceptibility to the effects of a drug, is not present.

Training for Caregivers and Compliance with Dysphagia Recommendations in a Tertiary Multiple Sclerosis Rehabilitation Center.

BACKGROUND: Dysphagia is common in persons with multiple sclerosis (MS). Speech and language therapists give dysphagia recommendations to persons with MS and caregivers. Nonadherence to these recommendations can increase the risk of aspiration. We investigated current compliance with dysphagia recommendations among caregivers and kitchen staff and assessed improvement in compliance by increasing knowledge through tailored training. METHODS: An observational cohort study was conducted over 4 weeks during which the compliance of the caregivers and kitchen staff in a rehabilitation center was monitored. A questionnaire was used to assess reasons for noncompliance. A 2-hour training session was provided for all caregivers and kitchen staff to improve their knowledge and skills. The compliance rate was observed again 1 and 6 months after the training. Compliance was defined by whether recommendations were followed. RESULTS: Results showed a significant improvement after training for overall compliance by caregivers (from 58% to >81%, P < .001). This improvement was still observed 6 months later (80%). After training, significant differences were found in compliance with the following recommendations (P ≤ .001): consistency of soup, consistency of liquids, food preparation, alertness, speed, amount, posture, and supervision. Recommendation for utensils did not improve (P = .44). Compliance with diet modifications made by the kitchen staff improved significantly (from 74% to >86%, P = .002), and even more during follow-up (to >95%, P = .009). CONCLUSIONS: Dysphagia training tailored to the needs of caregivers to improve knowledge significantly improves compliance with dysphagia recommendations and the quality of care.

The Impact of Cognitive Dysfunction on Locomotor Rehabilitation Potential in Multiple Sclerosis.

BACKGROUND: Cognitive dysfunction is a frequent manifestation of multiple sclerosis (MS) but its effect on locomotor rehabilitation is unknown. OBJECTIVE: To study the impact of cognitive impairment on locomotor rehabilitation outcome in people with MS. METHODS: We performed a retrospective analysis involving ambulatory patients with MS who were admitted for intensive, inpatient, multidisciplinary rehabilitation at the National Multiple Sclerosis Center of Melsbroek between the years 2012 and 2017. The Brief Repeatable Battery of Neuropsychological Tests (BRB-N) was used to determine the cognitive status of subjects as either impaired (COG-) or preserved (COG+). Locomotor outcome was compared between groups with the difference in 6-minute walk test (6MWT) measured at admission and discharge (Δ6MWT). In addition, individual test scores of the BRB-N for attention (Paced Auditory Serial Addition Test 2" and 3"), visuospatial learning/memory (7/24 Spatial Recall Test), verbal learning/memory (Selective Reminding Test) and verbal fluency (Controlled Oral Word Association Test) were correlated to the Δ6MWT. RESULTS: A total of 318 complete and unique records were identified. Both groups showed a significant within-group Δ6MWT during hospitalization (COG+: 47.51 m; COG-: 40.97 m; P < .01). In contrast, Δ6MWT values were comparable between groups. The odds of achieving a minimal clinical important difference on the 6MWT did not differ significantly between both groups. Only attention/concentration was significantly correlated with Δ6MWT (r = 0.16, P = .013). CONCLUSION: Cognitive impairment based on BRB-N results appears not to impede locomotor rehabilitation in ambulatory patients with MS. Attentional deficits are correlated to the extent of locomotor rehabilitation, suggesting the presence of a subtle effect of cognition.

The effectiveness of a self-management occupational therapy intervention on activity performance in individuals with multiple sclerosis-related fatigue: a randomized-controlled trial.

Purpose to evaluate the effectiveness of an individual self-management occupational therapy intervention program (SMOoTh) versus relaxation on the performance of and satisfaction with relevant daily activities in individuals with multiple sclerosis (MS)-related fatigue. in a single-blind randomized-controlled trial, 31 patients with MS (SMOoTh: n=17, relaxation: n=14) were randomly allocated to three individual sessions focusing on pacing, prioritizing, ergonomics, and self-management (SMOoTh) or on stress management and relaxation (relaxation). Outcomes (blind assessor): Canadian Occupational Performance Measure (COPM) (primary), Modified Fatigue Impact Scale, Checklist Individual Strength and Short-Form Health Measure. COPM improved in the SMOoTh and relaxation group after the intervention and 3 months later (COPM performance: F=13.1, P=0.001 and COPM satisfaction: F=10.4, P=0.001); nonsignificant group differences showed a trend in favor of SMOoTh. Modified Fatigue Impact Scale, Checklist Individual Strength, and most of the Short-Form Health Measure subscales did not change. Clinically relevant changes in COPM performance scores were found in 71 and 27% of patients in the SMOoTh versus the relaxation group. Both interventions seem to be feasible approaches to improve performance of and satisfaction with relevant daily activities in people with MS, with a sustained effect after 3 months. Neither program altered change fatigue (impact) or quality of life. Future studies with larger sample sizes are needed.

Is MS Intention Tremor Amplitude Related to Changed Peripheral Reflexes?

Intention tremor is related to lesions in the cerebellum or connected pathways. Intention tremor amplitude decreased after peripheral arm cooling in patients with multiple sclerosis (MS), likely caused by a reduction of muscle spindle afferent inflow, while amplitude increased when muscle spindles were artificially stimulated by tendon vibration. This study investigated the contribution of peripheral reflexes to the generation of MS intention tremor. Tendon reflexes of biceps, triceps, and brachioradialis, muscles were measured, using an electromechanical triggered reflex hammer. MS patients with (n = 17) and without (n = 17) upper limb intention and 18 healthy controls were tested. Latency of brachioradialis, biceps, and triceps tendon reflexes was greater in MS patients with tremor than in healthy controls and MS patients without tremor (except for the triceps reflex). Peak and peak-to-peak amplitude were not different between groups. It is concluded that tendon reflexes were delayed but not enlarged in MS patients with tremor.