Intrathecally administered baclofen for treatment of children with spasticity of cerebral origin.

Management of severe spasticity in children is often a difficult problem. Orally administered medications generally offer limited benefits. This study examines the value of intrathecally administered baclofen in the treatment of 19 children with severe spasticity of cerebral origin: eight of whom sustained brain injury associated with trauma, near drowning, or cardiac arrest; 10 with cerebral palsy (spastic quadriplegia); and one child with Leigh's disease. At the time of entry into the study, patients ranged from 4 to 19 years of age, and all were completely dependent on caretakers for activities of daily living. Children who responded positively to a trial dose of intrathecal baclofen underwent insertion of a drug delivery system for continuous infusion. This was followed by a double-blind trial of baclofen or placebo and follow-up review at 3 and 6 months, and yearly thereafter. Seven children did not undergo pump implantation because of excess sedation or poor response. The 12 remaining children have been followed for a period of 1 to 5 years. Favorable responses were present in all 12 children as determined by the Ashworth Scale, with the greatest benefit being reduction of lower limb tone. Except in the case of one child who had reduction in lower limb tone that resulted in difficulty with transfers, the caretakers all reported significant benefits from intrathecal baclofen, with improvement in muscle tone, behavior, sitting, and general ease of care being most commonly noted. Central side effects were seen in some children who received continuous intrathecal baclofen infusion and included hypotension (two patients), bradycardia (two), apnea or respiratory depression (two), and sedation (one). During a total of 568 months of pump operation there were 10 mechanical complications, including two related to pump or side port failure and eight related to catheter kinks, extrusions, or dislodgment. Pump pocket effusion occurred in five children and a cerebrospinal fluid fistula was seen in one child. Local infection occurred in three children and meningitis in two children. The results demonstrate the potential value of continuous intrathecal baclofen infusion for treatment of severe spasticity of cerebral origin. However, this treatment can result in significant complications and more experience is required before the long-term benefits can be determined.

Development of a clinical measure of postural control for assessment of adaptive seating in children with neuromotor disabilities.

The primary purposes of this article are to review the literature on seating assessment and to describe the development of a clinical evaluation scale, the Seated Postural Control Measure (SPCM), for use with children requiring adaptive seating systems. The SPCM is an observational scale of 22 seated postural alignment items and 12 functional movement items, each scored on a four-point, criterion-referenced scale. A secondary purpose of this article is to report the reliability of the seven-point Level of Sitting Scale (LSS). Interrater and test-retest reliability of the SPCM items and the one-item LSS were evaluated on a sample of 40 children with developmental disabilities who sat with and without their seating systems. Kappa values of .75 or higher were considered excellent, .40 to .74 as fair to good, and less than .40 as poor. The interrater reliability tests for the two seated conditions and the two test sessions conducted 3 weeks apart yielded overall item Kappa coefficient means of .45 for the alignment section and .85 for the function section. Test-retest results for the SPCM items were less satisfactory, with item Kappa coefficient means for the two seating conditions and raters of .35 and .29 for alignment and function, respectively. Reliability results did not appear to be consistently better among seating conditions, raters, or test sessions. Kappa coefficients for the LSS were fair to good for both interrater and test-retest reliability. Plans for future development of the SPCM and LSS are discussed.