ier oe tun OoLacien ASOCTON, EFFECTS OF ACUTE BOLUS AND CHRONIC CONTINUOUS INTRATHECAL BACLOFEN ON GENITOURINARY DYSFUNCTION DUE TO SPINAL CORD PATHOLOGY WILLIAM D. STEERS, JAY M, MBVTHALER, CHARLES HAWORTH,* DUKE HERREL, 4x "T. 8) PARK? rom he Drenden nd Nery, te ef Wii Hath en Cr A prospective, blinded study was done to examine the eects of acute bolus snd chronic continuous intrathecal baciofen on genitourinary function in 10 patients with severe spasticity due to tpn ford pathology. Genitourinary fuetion was assessed by symptotn questionnaires and urodynamic Studies performed after a olus dose of baclofen and 6 to 12 months after continuous ineathecal Isclfen. Rents were compared to placebo for scute bolus testing orto pre-continuous intrathecal buclfen values. Inall patients with iitative voiding and urge incontinence uninhibited badder contractions were ‘iminated OF 3 patients with an indwelling urethral catheter for ieontinence dae to detrusor hypersefeia 1 was converted to intermittent selfcathoteriation, Whereas bladder capacity, ‘ompliane, sensation and voiding pressures were not diferent after continiou intrathecal bacolen, ‘when a man ofall patients was compiled, « 72% increase in capacity and 10% improvement In compliance were abserved in subjects without cervical spinal cond pathology. Detrusor sphincter syne bladder compliance and abolished in 40% of the patients Continuous intrathecal berloten may represent trae hyperreleaia not eon tarugense isle wh hae decreased rd by oral medications, We promptly eamined the ant of ntathea alan ts prt of an vation ef patents treated wth this nino thai ed (GABA) ayn fr setts mule spa oF ‘pms of the lower sternite All pants eld bad mptons abd trodpaamse dhementtton sf lower rary ‘tract dafuneron fire eoing ntetheeal baclfe. Recee ‘experimental data sagen that Halon maybe ol the Inanagenent of wong disorders Activation of GABA ree {oes the pons and acral spinal cord thi mitaron 2a xtra stated ure ral ephincer ctl" Oral halter ‘nos bona ane to weasel me spasticity but ethers Beaten lite and Serious ae elects may oar’ ‘Wile itemac admiration ofthe GABA-T agonist bale fen. eyerisonlv airetfet on micturition autetieathe fal admiration ofthis drag as a. profound iniitory fal very gen voto te eo continuous Inelein for lower tatemity sane to spinal ord Batley" Thieme of drug delivery icweaaea the Ey of bclofen wie lesaning the andesite si fet tethargy weaned ad conison =" Since bulaen hasbeen ‘pore oiler blader funtion s rendomined placebo ‘onvolled double blind study was perormed Lovett te Seu and chron ects of ontinonaintetbes!bckten o feniturnat symptos aa parametere Pasi. As part fan investgtiona protest to examine ‘ho ficc of bar subracho ifs ‘of bacoen for ecw Wahean Cryst Bc 899 Roe Inteacable womati pasty or spasms of spinal rig (abe Tien an’ women 2 to earl tes age yur) wwreaustoned wah repr t9 bladder, bowel abd getua Faneton Spinal cord pathology in sje undergoing ela thon inloded 8 with spinal ter aja 9 quadrplgis wih ‘complete sens) an te loeb C3 ptiete 8 toe Paaplesic with TIL incomplete lon of sensation below Lt {patent 5) and a C incoaplete qudepesic wit nace sn. sition Ipadent 1). Pant 6 hall qutdripefia and Toss of Sensation below C5 ars rl of wap soon Patient ‘sth lack of seman below TO bee parsblope bee of Sringonyeia: Patents 8 to 1 tingnond with bereitary fustc parapets ad normal sensation bt hope deep tendon reflees below Li and sell mle sporty resule {agin difcls withazblion, Nerolopealdsotders had been present for to Ts years The pent wih mule sls ha progesive dietortion in neraogel function, Imanfeted at Ineesing cranial erveielverent iy Selanne che oe ure ‘Al patients hod viding complaints in ation to ever spaststy (Ashworth scare renter than 3} or involuntary ‘peste Of skeletal muscles (parm score eater than 21" ‘Tins voiding complaint inched wrpens, frauen. and ecorin (estate voidg, table 1). ay wail an low or Invermitentsecam, or bitaney. Candas were seated ter fae to respond or tlerate orl baclofen a ses of 60 {0 120 mg per day. Following an informe consent, appined ‘bythe Human Inesizataan Committe of the Univerey of Vira, pation ceed an staten tno ace 60 a) or saline trough the ES to Lt interspace tr pat of ‘tle bind prota o ealuste an effet on spacty. Pa ‘iets witht decree i sustcty o apa sof of rte ‘han 2 undorwentinplanation of programmable pur a the eoboutaneos pace othe ght upper abdoina wall A1880 [STRERS AND ASsociATES “haut 1, Ping ere nd 12 mont fer cis inal en a) Prue tometia Trae scene Spe ee i ai i a 2 clatles satgts Sugps POR ph Pant Abeta At 9 oats Ase rent Att Pent Pet Ala «eatin Fe Pmt | Alt bet ry 1 iat Anam) rake . rewat Abt Rett teat Abt Anat catheter was aneled through the eubewtaneous isso othe {nar L3to La vertebral love Phe eatetr was then inserted Ine the subrathoo pace andthe tip wos postioned a the ‘Tia wy 1 veer evel, Broudspeerom neti ere (Missed for anibctecalpophyni peperatiely and fora hours aor pump iplanacion. ‘Te pump was led sth 10g of 990 fee solution of blend ly dome Tested et 13 fo asthe ol done was requ to sheain ‘plant (rater thon 2 Asbo score eduction i sas HERS Te ate fafa we roles by an external ao Trequeney wand and pesried ang a pop computer ‘radar cing Tare chometzorae wor performed tailing rte of 60 por int mmecatelsDeforeintrathe: a bolus ning andthe at I and 2 ues terion of ‘thor saline baclofen, The inventiantors end patents were aware ef whether bocofen or sormal saline war admins tered. No otperuudypamie evaluation was performed daring the act bis sera Before pump inlantation « video tiedynemie fady won performed eal 1 patents, which nnsted ofa cytomettogam, pelvic for electomyoerphy ‘ithe patch ceo, pd etic urral pressure profiimetey inthe own Wick technic with ce pe inute per Tosion and 0 ei er second withdrawal aes To visualize the wrnmry tne ding loooaeopysadopagie conta me- Aig war ted during infin for te ektometropram, The ‘Video urodynamic uy wae performed i teste mathe ‘ents in the supine position. Mean values were shined fe apne, viding pret, wolme to fe snstion, resid Ae and mania urethral resure Blo compliance was ‘imate ete difference in ame copay or mitriton ‘vided by the corresponding change io detrusor presure tn {reveal presaue mine rectal presse) eal lieasound (tae prdnted wo exanine the spper rina tat "eo urmiynane tenting war repeted © months to 1 eee afer pnp plantain. A uigrami esting the patents Steg onan efi dow of tacloen to contol somatic eps Tis or imoluntryspunmn No attempt wes de toast ‘The doe of baclofen to lereon inary tae enptoms “stot, Urodvaami. parameters were compared beloe (consol and afer sete bi dosing sd ding continous inertbeal btn ting the Wilcoxon ranked sm nonpars test test. All valves are presented as man los oF ins ‘Sand esr ofthe mea Pre acon omatiruundynamic. A preoperative esto. secivgrem revealed that patents 8 and 8 had ninbied {ror eonractions thi sosmnted or the symptoms of i {sve wing, urge intontnene or nocturia (able 1) Com ined "eystretogrphie electrographic data demon- ‘rset outa ptt 2 tof apd 8) lacked sori fon beeen bleed extnnn etal apne ith Tr inceasen perineal clecromyogrape activity efned as mocspnnder eveymea The lek of ecoednaion re ‘Sled in pret residual urine tall 3 patients (9 56 ce Patient hd seidal urine atrbted to poor stained throne contracn, Of thee € patients 5 rpared beng {teed for meeptomaticraay tat infections within 2 ears tour eraastion. Maxim urea (84 = cm. water) and Sing (8 1 cm, water preaures were elevated for the [oun wile iron woune was dcrented (Bl = 163 ee) Ecmpiced to vain repo for oral ads (ig. 11" No ‘Speet had hyroureteronephons or loes frenal parenchyna ‘on ltoeoundevluon hough all patients possessed @ tBickoned badd wal Tree C3 quadiplegies (patents 2 to {seed epende of oitomonse dsrefeia mais Glaphorens headache andor vilual datrbancs esoated trih sync hyparesio. Preoperative ll patents Thutedc-altenetcontageniste eeinint o owen episodes ‘ atonomie dren "fetes Aste bos administration of baclofen (80 9) swt tolled hy statiical safientinereses (D <9) olue fie seonan tnd blader omplioce a 2 hours Ute dosing when omc inrabecl sli (Bi 2) All 10 potions end bo pp nratbecl acaen with an verae dose in spastic of rater than 2. the Ashworth ‘als thuy, tes underwent pump implantation, ‘hemi tc, Al Indes reported a subjective cane inode sanpons ae ry a 6 bout fe rtitation ok fentinaows bclfen terns Dosages at evaluation ranged ‘fom B ta S12 ya or day ean 230), Followup ranged fom 12 to 28 mont nen 1), Patines 4, © an? required an Indwelling etal catet’ bear of faze of anispasned ies anteplpeg and npramine to contol urinary ion tinonce whieh tally wasattbated to ders hypereen Lor» smal apace, poly complet We, Video uo ‘amie toting nthe 3 en (patents ae 6) eval @INTRATHECAL BACLOFEN IN GHNITOURINARY DYSFUNCTION 1651 “| e i i coneeat sactofen ‘conceal asclofen 8 Compliance (ee/em, water) & Volume (ce) epee Voiding Pressure (cm water) control sclofen Dose cace./day) capacity t= Conptiance ‘ung wn tlle B, heise Bie copy teed sa ewet ns gi Crier oer increta ra et sil soups Die pre pr ce slighty open badder eck and ue only de long {erm rthraleathteztion. Wl om omtnano neh, Uielofen howe 2 patients reported decrease leakage ard the catheter ‘The romaiing man (patent 7} converted #0 Intermittent seleeailorieation without urinary incontinence between istrumartatons A fll eonntogra i the Individual revealed + 40% iereme in Madde voli and Increased compliance Before basiofn patients 1 and 81010 with volustary vote, noe uray lregueney or netaria (a1 212 eo 0a 2 Ol per evening! deypte mticholnerae oF Imipramine therapy. While on contiaves intraheal beaten octara was deerened to Ob =O. epnes per evening fp 205, OF ¥ pens on len cnt tie ‘oidingftaptone or incontinence 8 patients 8 10) di et ‘euler mediation once nent baclofen we aie. ‘nt aly sees Fe! olde ee eal ue at ces oda von ver pee chants tae eas "Table 1 iste the changes in simptome following sentisuous intrathecal bacon Tn contest os teored improvement in symptoms, wo amie testing we months tot year following aration OF the baclofen puns did ct real sgn chang In ro ‘jum patentee fo the ese population snr investi tion (able 2). Patent 1 ith pata quadepeparfoed re ested uredyname evasion although he ated» 0% de {ets in uinaryfraueney td mtn: Fue {highlights the individual varality i repone to intathca hate ‘Hay hugh suis 010 demoed much a 0 increne ir ber capacity oF compliance, other ip {lente 2 tt and 6) shoved decreas tise pane Mean rsd urine in ein pants (patents 9 and) roto increse dria continous intrathecal haclten GIST Sr co despite eadeation of tre spines dy=_ ~g aa : L * _ 2 2p £00 3" = £4 a i i ? fy i. "FAS hse apy al a he coup “Tams 2. Urano ole iat cel eon Sh ee ne iki ease le sd D, ne hange ee pu re ontr on at nina inate on in tein Sere em BE a argnin ef bjs ptt Tenney dow of le LP ‘rie mere bnlleved totem fom he ability of baleen to TRhuhic micron, Uredynamicsconamed thet poorly mus tained deus contraction ar continu intrathecal Dl {enennriatedodcested blader empsying The elimination ‘ot involuntary detrusor contractions 02 patients also con ‘Shent wi the abit of intarthecl baclofen to Init reflex “Av ional benefit of inteateelMaloen wat the lin note or marked mpewveent in autnomie dart in he Saundrleges (paints 2 eo 4} Of tae pallets ano Toner on sadrenerae blockers whe patent 3 continues {ake tcruoain for rare epiedea” Catheter diledgement oe ‘ned in thi ter patient 1 Sear ater pump mplaration ‘Ind the frst maneation of baclofen wichsawal as 6 piso of estonomic drei. nan efor uo ivetgate whether the Ick of changos in men urysic parameters read rr dfrehes inthe ferplines and capacty were com fitlen donee of baclofen, With Iinear represion soa Feifinntcorsation cod not be made beeweenbecofen ‘defor fren pation and the change In epacty (r= ‘bey ox complinace (r= 0.0, fie, F). Honeer in ab Inuividel (patents [to 2} an increas in baclofen dose un Feri inhioed blade acts toe rete extent and ould fen induce wary etegton. In thee 8 ube dees of ‘Rela anuciaed ith dear areleia produced fcitty Fh lower extremities adoring indpendent transfers ot Shnalaion To evant mete the eel of spinal cr sion inuenced uredyramic raponss 1 balfen, qusdplnie (Daten 2 tod and 6) vee excluded fom the anaes of ‘fodynaie dita. This alps showed that Blader compl hve and eapacty were igual increased (p 0.08) nthe Shonqupees ‘Pontperatine complictins inched ataletasinn? patentssud prolonged (1 week) cembrspinal Mid leak causing ‘hous and heacacbes in 2 Wherun no mechanic prot {ems itn the prognmmable pump have ben encountered Ahving the ft 18 monte cmpiations due tothe pal father were pt ntsc. One pent had cezebeapinal ad leakage round thea estheer eng eins A ptient rotfred 9 catheter dary foent ofthe inti eateter These tomplcations with the inc he a ait hon er em Dertoneal chante N> subject had infects completions [Aithouh2patenis with an indweling urethral etter, ah 2 wie qeadplgi and flex oidng onstrated sna fiom of urse mith greater than 0 eoonforming ste of Tnceria smptomett rinry test ineeuons have ‘ot ‘Sigican side efts wee sera in patie setiving ‘continua lnetbeel baton in aston to rusia ue ‘ary reenion in patients telatively igh (renter than Stu. per dy) dent bucloe, lon oe emprary lee decrease in tate (relenopei) pail stction set ‘api (0%) ierassin baclofen dwt alhougnactrnl ot Inorrng erections weve preserved Purr, ef puiente Tied om increase i contpaion guinng 4 Blot adr ‘ent in the bowl progam” Iti pustulaed that baclofen, {shite viscera alleen npst to the loess spinal ord ‘hereby proving meses, aa oe ny ne ay pe ie ect ae i ephedra Eee eee a gas cea Soest ct at a ae Sei re cee Dery temararyeanes: oo Seen mile pit ea hero inthe rs ah gr el igi sim trea eta See omar acta ametuer: Sha Soe vay a Deen ate i a SSE ee pea est oma Senta Ect ee ‘Shae eee a SES ee fa ae cc Seepage ages ese SEN hie cigar Seeger ace pine Tete ese lt cee mop afc anes, ta Scie de canaries een eration one mene torrente {2ucrOURIKARS DYSFUNCTION 185, sentra ede tat, euch lethary and confusion. ‘his is free enbaneet by dee dus vasnion atthe ste ‘ALO patient wit pial cord abnormalities presented with symptoms af lower non tat dysfunction. Symptoms of Srnay urgeney,feqeeney,noctara or oconinense do ‘trary hypereena were eed or had with neathe tal selfen Ancor eee of sete bk tte of ticfen eas foinerease the solame atthe ft sensation of fling. Fathermere in sme spinal cord injry patente on fontinanar intrathecal bulten resin! rine tly a teased. These ndings ate conlstet wth te ost site {ef teton af ntethcel baclofen on priaty alee emia inthe spinal cordon expan the bo hs dug tot Fee detrusor atts Porter, enorme onan einige Ivey erokedseuel and bowel neon minions the cone ‘hat this GAMA agonist init parva inp to the inal cod in hans _ Theravnos caf ha been howto be saprioe to oa sing in'liminatng detsor bypereixin itrvesas ‘Miinistation cam anscnted with eer nervous sytem Eid eet and not praca for iia er} sy aete inate cin wa ot niet micron n Dents with stave and ge incontinence To int tigation Lof 3 patents mth sn indwallng urea ether ‘i ale to convert to interatene mallorca, Phe {her 3 pale cated ae wie age rtd restr range of motion forthe ler etemiies fed Intermitent caheteraton i | pest. Silay Nentngs feat demonsteated that he eof inane intrathecal acter awed 3007 pans with conten de 0 hear byperefiss,uttesponsve to orl mediation, to ‘convert trom an ndelingwrethrleateter do inert iron’ Sethe cin reo en body inthe rine tae paces the ten Tk Sor Inetion stone formation an en deteroan, conti {Pimemitntcthcratin press icant aver im uologeal ranagesene Bladder compliance was also inresed after bls dosing for the ante group sod fe nemqndrpoges ov conisous trate balten.Previuly. bade compliance has be Tnevedo rete prima he inne clr proper the bee sather than the eet of conta ner inp= ‘The ineece of izes! bolofen ober comiane lh that astonom eet fron the andorra spina ‘ond aie: this urodynamic parameter. ecres in ble omplisnes in patente with pin dane can produce by ‘tones and ena deterraion To nce blader ampliance might seprvest anor bee eft of i tratecal baclofen in these aes bat mgt ste ae ‘ead to con that inition of decor ett ad Increased bladder oman proven real deervaion ‘Anther propised benef hare sarc the spasticity of dveyneria ofthe sted tl omponent the estegnal urechrel spacer, heres racing vat fea fan" Tie acon woald be expected to owe? teidua, ‘ie and decree voiding presure We dd ot fins ‘deans in ail url o olin pressures ethouth 2 plete had decrust sphincter dyesmer that wa lessened {roma elininated on cletrorsyogaps Heese path ead of concent node ctremogranhy etree were ‘ed, cot be conta that sted sphincter aly tea abot. Hzctrose plant inthis inenaton and in Previous sd" could alo scount for dierenes beineon Drsperative and postoperative sts Howe, accumalating1854 seers AND idence supe that intrathecal baclofen ints the extern tm see uci of {ever micturition probably expan the persstnce of eeated ‘anal rio epi docs in exeral eel sphincter Perec n-evimale i has ben propose tha ntathcalbelten can eliminate pain taeoited with bly fnlammation = Indes ation nated sgafcae decease in blader poi {olloning continuo ttathea!falofen bas been rev ‘ly pespnd thst intrathecal belt only eliminates pin ‘SSoudtd with ernted muscle epetcty However, bw ‘lofen na ln sflence visceral pin, since met te tat termite in tha rel ben te also hinted by SGAIAmuneene drape’ "Poe efecto cota inteehecl bacon oe nay rest fancion nny not be clinically fli al potent Taint fects may onl beached ac dose sored with thus sho afete, For example the dave of ctf had ‘ertered to avoid abolishing tele Dnder empeying tn 2 ‘tne In ado, some subjects the due nese hacen rowed to even incontinence exe acct ‘ofthe lower xtemities or inpotence Unwaranted sie effects Sree minimized ty the pump design, which allowed precise ‘eral cont of ce and tea every ‘ter intrathecal sent have been reported to inhibi od er anc in aman Aeut atte elon inhats ‘tnddesfuneton Inerathecl morphine inhibits detrote 2 ‘hy y aration of apt reeepars inthe spina cond Tnteathecel morpbin lo integer he acto the external “ueival spinor thereby ring travel pressure which ould lad to icrnsed reel vine a Rpdronephrs.” achermore,sgncan tolerance develops thie opt re fing a Progmanive and prove inerese it dine” In {Snr t morphine, bacon ite eis blader acuity ‘Siku incresing tate onstancnTelerance to eeofen Urseope canbe managod by pert incense dosage “ther drugs that inflsence blader finetion ay ale be conde for contnunas seatoel deliver. For example, xpeiental ata animals inst Cat nuratecl sro’ bere mou and stone antagonist aii veflen mie {ankion® Like beaten, these drs may be benefit In treating intact rary ineontinenen de to dts hy penefein: Alternatively, strathecal dopamine agonist ac ar mitten selexputays and cold be wef in fl Tithe bse empeyne Te lack of fet of eontinaoaintrathea bacon on mean srodynuns paretere, despite tbe significant decense in eoston or complane high cl ceebrospin fot doe ce the development of tlerance with continuoas [ion On ay iin bai improvements iy sympa, ler unary tect management and rodynanie changes often ‘ceured wh chronic baleen adinitration, A seca for hn wari may te theft of tbe undorying spina athoogy. In ongedrplegic patents improvaments a bl [ercapaiy and compliance were niga ae) Lak of {mpswvemens in qoadipleges could be exphined pay [Sos ofthe ladder secondny to long er catheterization ‘Vath in unynsiieparareers ering bcos infosion tiny aso be ue to fernces im neural enganeation or atl within he rostral spinal cord folowing je ‘Oral erapy with sntchinrles or try antidepres sate bars med ty to trent. mams lower wsinay trot Gdaorders copes thowe seocated wa deers Rupee Mina por baer compliance. Intestheal dru dalvery rspovts potentially ful leernative to factate urine ‘Nbrape:"T free of ti iavetigton indicate th «po pectiestaty i warranted in which the dove of coins intrathecal bclofen would berated to blader dysinction ina group of paint ith wel defined spinal pathologies and ‘lng ordre otal du oliver epesents sig [Rant edvance nthe pharoncaloia!terpy for somatic ane ‘acral igorders ring fom dafuncton oh hier “Sina cont, The cot, sde elected ned fr sn operation ‘est hn hs thers sd only be arden patents ‘the haye aldo oa gees tke onseretive menses For ahestal imce spn, and possibly trinary incon fence or cred bladder soaplan. "Delage Ses provided valle astance in this study 1, Ronin HL, Kanan and Kein, He Un vo acs of ‘Cetnsncbay age Ce nary aie ta etree ican Sept Phares 48,0 scr By Rv Rink Re i de Maggi‘ CX, Santen, P- Gain 5, Puro, M Cone, ES eon td Te le ao Ritiodbenge ck Paes 3900270 1 NBER ME pcs Py Coie Band Mal, "Sia annoyed emperor ation ito ee 3H Po, a Mag Pe Sat, N- ant ene. Una tan te secluded morphine Sos Ura et a 188 Pinto 6 eS Polar Mand Debone efitarational ‘ine as nh ron ete ed yc 5 48:1 1, Roan MS, Abram A. Sand Fel A: Boban ets ‘anispouiey digs om euptvan th nse Had, Seg Bs St suo ST owstn St Sabian AS. Late S.A and eb A lr ig tr ein ino ee Tir Hd Ser, We Leal i th uation of “towed dtmetin Ut Ta $0 65,18 athe. andres Cs ad iabraary nent te fay of no cl per a ‘Taplor, M.C. and ates, P= A double Mind cromover al BakGersin, so ~“_ ttlgas Be Fad Peon Re Bie of taba TREES de lsat ftom 3 il, 142 10, Was meray rs re rn 8 gm ral he Pag it Ds Son hy Corsa Dy, Lash, iy Gotti, en sai ne ‘on G2 Senter Aborto A brit BGs ace Ber fade STs and eae ‘ed wate boa nto eis flonan Nee Pt 1, Saline, BV J. ais and “pth se ah tn ‘Slee pt Rg a ees Tee ANS Ita ttn ready cpa $a ate ik angina! Stew" han Tot © Me Gnas tli 3m einen ihn nen ‘puppies hig ed ane Trnaats wba Gace Pi ace gees Ec ty Rs See erat Rt fds Chr nptn. eat SRT Cat 8nd D3: Heal icINTRATHECAL BACLOFEN 1 GRNITOURINARY DYSFUNCTION 18565, gia moro nine Ul, 40:10, Ua tintin dig palo th thn nd obi apa san aon Fae 3106 1S 22 MeCaie and Brady, S: Dstt dsm. 2% Hema AE Water M,C kes Fo Wise raga tu Tin anf a ner nd 2 wh Wn CF Tumba ove, Ge ‘ein nea a ie aoa Bae {ia lcd Neuen ot 2 Mean Ms oD Soa a Waiters. Fe ee ee ee Gon end pasty el Cel pens as lesen a ph, Neto AA Saber SS 2% A Ly Cane, Sema, VY Mags Csi 8, a ‘Me A Ato forse pi rie fom he iy che in comuioun fey 3 Ul 484 Whi and Yoke, alten atincetie nhe "emanate pte ania Bu Parma 812, 8 11 Bn, Samal, A Sima, Den, Band Mara,