Intrathecal baclofen for dystonia of complex regional pain syndrome.

Dystonia in complex regional pain syndrome (CRPS) responds poorly to treatment. Intrathecal baclofen (ITB) may improve this type of dystonia, but information on its efficacy and safety is limited. A single-blind, placebo-run-in, dose-escalation study was carried out in 42 CRPS patients to evaluate whether dystonia responds to ITB. Thirty-six of the 38 patients, who met the responder criteria received a pump for continuous ITB administration, and were followed up for 12 months to assess long-term efficacy and safety (open-label study). Primary outcome measures were global dystonia severity (both studies) and dystonia-related functional limitations (open-label study). The dose-escalation study showed a dose-effect of baclofen on dystonia severity in 31 patients in doses up to 450 microg/day. One patient did not respond to treatment in the dose-escalation study and three patients dropped out. Thirty-six patients entered the open-label study. Intention-to-treat analysis revealed a substantial improvement in patient and assessor-rated dystonia scores, pain, disability and quality-of-life (Qol) at 12 months. The response in the dose-escalation study did not predict the response to ITB in the open-label study. Eighty-nine adverse events occurred in 26 patients and were related to baclofen (n=19), pump/catheter system defects (n=52), or could not be specified (n=18). The pump was explanted in six patients during the follow-up phase. Dystonia, pain, disability and Qol all improved on ITB and remained efficacious over a period of one year. However, ITB is associated with a high complication rate in this patient group, and methods to improve patient selection and catheter-pump integrity are warranted.

Shoulder pain and external rotation in spastic hemiplegia do not improve by injection of botulinum toxin A into the subscapular muscle.

OBJECTIVE: To study the effect of botulinum toxin A in the subscapular muscle on shoulder pain and humerus external rotation. METHODS: 22 stroke patients with spastic hemiplegia, substantial shoulder pain and reduced external rotation of the humerus participated in a randomised, double blind, placebo controlled effect study. Injections of either botulinum toxin A (Botox, 2x50 units) or placebo were applied to the subscapular muscle at two locations. Pain was scored on a 100 mm vertical Visual Analogue Scale; external rotation was recorded by means of electronic goniometry. Assessments were carried out at 0 (baseline), 6 and 12 weeks. RESULTS: 21 patients completed the study. We observed no significant changes in pain or external rotation as a result of administration of botulinum toxin A. External rotation improved significantly (p = 0.001) for both the treatment group (20.4 degrees (16.6) to 32.1 degrees (14.0)) and the control group (10.3 degrees (19.5) to 23.7 degrees (20.7)) as a function of time. CONCLUSIONS: Application of botulinum toxin A into the subscapular muscle for reduction of shoulder pain and improvement of humeral external rotation in spastic hemiplegia does not appear to be clinically efficacious.

Treatment of recurrent posterior dislocation of the shoulder in cerebral palsy by injection with botulinum toxin A into the M. subscapularis.

SUBJECTS: A 20-year-old woman, known to have cerebral palsy and a spastic hemiparesis, suffered from frequent (up to 20 times a day) and painful posterior dislocation of the affected shoulder. INTERVENTIONS: For the last two years we have treated her with injections with botulinum toxin A (100 U Botox) in the M. subscapularis. RESULTS: Pain and dislocation rate have improved substantially.

Discovery of molecular hydrogen in a high-velocity cloud of the Galactic halo.

The Milky Way's halo contains clouds of neutral hydrogen with high radial velocities which do not follow the general rotational motion of the Galaxy. Few distances to these high-velocity clouds are known, so even gross properties such as total mass are hard to determine. As a consequence, there is no generally accepted theory regarding their origin. One idea is that they result from gas that has cooled after being ejected from the Galaxy through fountain-like flows powered by supernovae; another is that they are composed of gas, poor in heavy elements, which is falling onto the disk of the Milky Way from intergalactic space. The presence of molecular hydrogen, whose formation generally requires the presence of dust (and therefore gas, enriched in heavy elements), could help to distinguish between these possibilities. Here we report the discovery of molecular hydrogen absorption in a high-velocity cloud along the line of sight to the Large Magellanic Cloud. We also derive for the same cloud an iron abundance which is half of the solar value. From these data, we conclude that gas in this cloud originated in the disk of the Milky Way.