Brief History. F.D. is a 28-year-old man who sustained complete paraplegia below the L-2 spinal level during an automobile accident. Through the course of rehabilitation, he was becoming independent in self-care, and he had begun to ambulate in the parallel bars and with crutches while wearing temporary long leg braces. He was highly motivated to continue this progress and was eventually fi tted with permanent leg orthoses. During this period, spasticity had increased in his lower extremities to the point where dressing and self-care were often diffi cult. Also, the ability of the patient to put his leg braces on was often compromised by lower extremity spasticity. The patient was started on oral baclofen (Lioresal) at an initial oral dosage of 15 mg/day. The daily dosage of baclofen was gradually increased until he was receiving 60 mg/day. Despite the higher dose, F.D.’s spasticity was only partially controlled, and he still had problems when he was trying to sleep or during ADLs such as bathing and dressing. Problem/Infl uence of Medication. The physician wanted to further increase the oral dose to 80 mg/day, but the therapist was concerned that this would create sedation and cognitive impairments. Moreover, F.D. had already noticed some weakness in his arms and upper torso due to the effects of baclofen on his nonspastic muscles. A higher dose would probably cause additional motor impairment to the point where his ability to transfer and ambulate would be compromised.

1. How does baclofen work, and why does oral baclofen affect F.D.’s nonspastic muscles?

2. Is there an alternative way to administer this drug to better focus its effects on the spastic lower extremity muscles with less effect on F.D.’s trunk and upper extremities?

3. How can the therapist address alternative administration methods with the physician and patient?