Microsoft word - gait evaluation before and after intrathecal baclofen therapy- a 6-year follow-up case study-publishion .docx
GAIT EVALUATION BEFORE AND AFTER INTRATHECAL BACLOFEN THERAPY: A 6-YEAR FOLLOW-UP CASE STUDY
Shuyun Jiang1,2, MD, Nancy Lennon3, MS, PT, Chris Church3, PT,
1 Orthopedic Department,&3 Gait Laboratory,Alfred I duPont Hospital for Children,DE,USA
PATIENT HISTORY The patient initially presented in 2002 as a 22-months old male with a diagnosis of diplegic type
cerebral palsy, was referred to orthopedics for a delay in ambulation. He was born 4 weeks early without significant medical incident. He walked independently at age 2 yrs. He is cognitively normal, does well in regular school. He had an intrathecal baclofen pump placed in 11/ 2005. In 2008 he underwent orthopedic surgery, which included bilateral femoral derotation osteotomy and distal hamstring lengthening to get him into a more upright position and out of the internal rotated position. In 2011 he and his family were considering removal of the baclofen pump, at age 11. He had gait analysis in 2002 2003 2004, 2005, 2007, 2008, 2009, and 2011.
CLINICAL DATA Clinical evaluations were made before and after intrathecal baclofen therapy as well as orthopedic
surgery. The patient showed improvement in muscle tone and passive ROM after baclofen use and surgery. On 04/25/2005 he was given evaluation before baclofen pump. The patient had significant spastic diplegic cerebral palsy with very high tone. He cannot get his feet flat on the ground. Popliteal angles decreased to 25 degree and the tone of muscles declined from 2 to 1 bilaterally during baclofen trial.
Table1 Change in passive angle and tone
§ The time of pump insertion was in November 2005.The date of pre ortho surgery was 23 months after pump insertion. The date of post ortho surgery was 6 years after pump insertion.
GAIT DATA Gait analysis was performed before and after intrathecal baclofen therapy as well as orthopedic
surgery. Before baclofen pump insertion step lengths were lower and cadence was higher bilaterally, ankle joints were not stable in three plane, increased hip and knee flexion, external tibial
torsion in right,femoral internal rotation bilaterally. Vertical GRF showed foot contact force is very
high , the first peak was approximately 2.3 times of weight in vertical. Gait kinematics and kinetics were improved and more symmetrical especially after intrathecal baclofen pump insertion and orthopedic surgery.
Step length Toe in/out GRF (15%) GRF (30%)
§ The time of pump insertion is in November 2005.The date of pre ortho surgery is 23 months after pump insertion. The date of post ortho surgery is 6 years after pump insertion.
TREATMENT DECISION AND INDICATIONS
The patient’s initial gait parameters and clinical data suggested increasing spasticity. He was a
candidate for intrathecal baclofen therapy. After a baclofen trial test that showed no deterioration in his gait, he received a pump. Six weeks post-op baclofen pump insertion, the patient’s mother noted that he had been doing very well. She was quite pleased with his movements and the decreased tone, he had significantly improved overall gait. After 3 years with further gait analysis he had orthopedic surgery. Then 6 years after insertion the baclofen pump was running short of battery life and the family wanted to explore removal vs. new pump insertion. The baclofen dose was gradually weaned to a minimal dose for a trial to determine future treatment course. The dose turned from 120 mcg to 90 mcg, and then turned down to 30 mcg. Using the follow up gait analysis a decision will be made about pump removal or re-implantation.
SUMMARY This case describes the use of gait analysis in decision making for intrathecal baclofen use and
followed by possible pump discontinuation in an 11 year old male with history of spastic diplegic cerebral palsy. The baclofen trial demonstrated a gait pattern with minimal change however after 3 years of ITB there was much more improvement in the gait due to reduced tone, which shows the limited utility of intrathecal baclofen trials.
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