ZDRAVLJENJE IZRAZITE OVIRAJOČE SPASTIČNOSTI – KDAJ JE UKREPOV PREVEČ ZA PREMALO UČINKA? TREATMENT OF SEVERE DISABLING SPASTICITY – WHEN IT IS TOO MUCH OF INTERVENTION FOR TOO LITTLE EFFECT? mag. Klemen Grabljevec, dr. med. Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča, Ljubljana Poslano: 25. 3. 2023 Sprejeto: 4. 4. 2023 Avtor za dopisovanje/Corresponding author (KG): klemen.grabljevec@ir-rs.si Povzetek Izrazita ovirajoča spastičnost predstavlja generalizirano ali lokalno razporejeno spastičnost, ki po mnenju pacienta ali skrbnika predstavlja velik ali popoln problem na področju telesnih zgradb in funkcij ter dejavnosti in sodelovanja (1). Pacienti z generalizirano in večsegmentno ovirajočo spas- tičnostjo, ki je neodzivna na oralno zdravljenje, so kandidati za zdravljenje z metodo vsajene baklofenske črpalke (2). Bolniki z žariščno, večžariščno ali segmentno spastičnostjo so kandidati za zdravljenje z vbrizganjem toksina botuli- na v tarčne mišice v kombinaciji z drugimi terapevtskimi ukrepi (3). V primeru, da z vbrizganjem toksina botulina v priporočenih odmerkih pri bolnikih s segmentno spastičnostjo ne dosežemo ciljev, je potrebno razmisliti o zdravljenju z metodo baklofenske črpalke oz. kombinaciji obeh metod. V primeru, da z vsaditvijo baklofenske črpalke pri pacientih z večsegmentno ali generalizirano spastičnostjo ne dosežemo ciljev, je treba razmisliti o uvedbi pridruženega zdravljenja z vbrizganjem toksina botulina v tarčne mišice. Določanje ciljev zdravljenja spastičnosti in vsaka uvedba dodatne metode zdravljenja mora biti sprejeta v sodelovanju in soglasju s pacientom in svojci (4). Zdravljenje spastičnosti z vsemi metodami kot tudi preprečevanje sprožilnih dejavnikov za povišan mišični tonus je interdisciplinarna dejavnost (5). V prispevku bo predstavljen primer zdravljenja dveh bolnikov z metodo vbrizganja toksina botulina in vstavljene baklofenske črpalke, prikaz določanja ciljev in vpliv na breme spastičnosti pri dejavnostih. Ključne besede: spastičnost; baklofenska črpalka; toksin botulina Abstract Severe disabling spasticity is described as generalyzed or locally distributed spasticity which is perceived by the individual or caregivers as severly (in major or total degree) hindering body functions, activities, and/or participation (1). Patients with generalized and multi-segmental spasticity which is unresponsive to oral therapy, are candidates for treatment with the implanted baclofen pump method (2). Patients with focal, multifocal, or segmental spasticity are candidates for treatment with botulinum toxin injection into target muscles in combination with other therapeutic methods (3). If the goals are not achieved by injecting botulinum toxin in the recommended doses in patients with segmental spasticity, it is necessary to consider treatment with the method of implanted baclofen pump or combination of both methods. In cases when goals are achieved in patients with multi-segmental or generalized spasticity with implantation of baclofen pump, it is to consider adjuvant treatment by injecting botulinum toxin into the target muscles. Setting the goals of spas- ticity treatment and any introduction of an additional treatment method must be accepted in cooperation and agreement with the patient and relatives (4). Multidisciplinary input is essential at all times to optimise spasticity management programme and manage spasticity trigger factors (5). The presentation will present the case of treatment of two patients with the botulinum toxin injection method and the implanted baclofen pump, goal setting and the impact of the burden of spasticity on activities and caregiving. Key words: spasticity; baclofen pump; botulinum toxin Grabljevec / letnik XXII, supl. 1 (2023) 20 Literatura: 1. Creamer M, Cloud G, Kossmehl P, Yochelson M, Francisco GE, Ward AB, et al. Effect of intrathecal baclofen on pain and quality of life in poststroke spasticity: a Randomized Trial (SISTERS). Stroke 2018; 49: 2129-2137. 2. Saulino M, Ivanhoe C, McGuire J, Ridley B, Shilt J, Boster A. Best practices for intrathecal baclofen therapy: patient selection. Neuromodulation 2016; 19: 607-615. 3. Francisco G, Balbert A, Bavikatte G, Bensmail D, Carda S, Deltombe T, et al. A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: an international group consensus. J Rehabil Med 2021; 53: jrm00134. 4. Ashford S, Turner Stokes L, Allison R, Duke L, Ba- vikatte G, Kirker S, et al. Spasticity in adults: man- agement using botulinum toxin – National Guidelines 20 March 2018. [cit. 25. marec 2023]. Dostopno na: https://www.rcplondon.ac.uk/guidelines-policy/ spasticity-adults-management-using-botulinum-toxin 5. Biering-Soerensen B, Stevenson V , Bensmail D, Grabljevec K, Martínez Moreno M, Pucks-Faes E, Wissel J, Zampolini M. European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type A. J Rehabil Med 2022; 54: jrm00241. Grabljevec / letnik XXII, supl. 1 (2023) 21