christina a. hughes, md director, ms regional program va puget sound hcs

Christina A. Hughes, MDDirector, MS Regional Program

VA Puget Sound HCS

Tightness or stiffness in the muscles that impairs normal smooth motion.• May be beneficial:

Improved “strength” for transfers/mobility Improved blood flow Decreased swelling

Treat Spasticity when it begins to interfere with function, care-giving or causes discomfort

Stretching and other modalities Oral medications

• Baclofen• Tizanidine• Clonazepam• Dantrolene• Valium• Gabapentin

Injections• Botulinum toxin• Phenol

Intrathecal Baclofen

Reduce spasticity that interferes with activity, care and comfort

Facilitate rehabilitation therapies Improve function Improve ADLs Prevent spasticity related

complications• Pressure ulcers, contractures, pain

Reduce caregiver burden• Improve hygiene, transfers, catheterization

Small Titanium Disk (3cm diameter x 1cm thick)• Refillable Reservoir for liquid Medication• Computer chip regulates battery-operated

pump Flexible silicone catheter directs

medication to intrathecal space. Pump refilled every 1-3 months Pump replaced every 5-7 years

Person with MS who has significant spasticity that interferes with function, care-taking or causes discomfort.

Other therapy options are ineffective Other therapy options have too many side-effects Person is able to comply with refill and maintenance

schedules Person lives in an area that has quick access to care in

case of pump system difficulties. Person has sufficient body size to implant pump system Person does NOT have an active infection Person does NOT have hypersensitivity to baclofen Person has trialed test dose and had effective response

Try before you buy theory Given test dose of intrathecal baclofen

inserted through a needle. Works in 1-2 hrs

• Look for improved ROM• Look for reduction in spasticity

Wears off in 4-8 hrs May not be perfect dose

• OK because pump is fully titratible and programmable

May repeat test trial at different dose

Requires General Anesthesia 1st incision – Lower Abdomen

• Create a pocket for pump beneath skin (above muscle layer)

2nd incision – Lower Back• Insertion site for catheter to enter

Intrathecal Space Catheter is tunneled from back to

lower abdomen to connect to pump. Incisions heal in about 2 weeks

Anesthesia risks Bleeding Infection Spinal Fluid leak Initial alteration in bladder control Initial alteration in spasticity control

requiring titration of intrathecal medication

Pump Malfunction• Delivery of too much medication

Baclofen Overdose• Delivery of too little medication

Baclofen Withdrawal Catheter Malfunction

• Kinked catheter

Symptoms• Drowsiness, lightheadedness, dizziness,

somnolence, respiratory depression, seizures, loss of consciousness or comma.

Treatment• Be evaluated by a physician immediately• Maintain proper airway and breathing

precautions• Empty pump reservoir• May be given physostigmine • May have Lumbar puncture to reduce baclofen

in CSF

Symptoms of Underdose• Itching, low blood pressure, new sensory

symptoms, fever, change in mental status Symptoms of Withdrawal

• High fever, change in mental status, severe increase in spasticity or muscle stiffness.

• In severe cases can lead to muscle breakdown, multiple organ failure or death.

Immediately contact a physician (or ER) that is experienced with ITB therapy.• Even if symptoms seem mild• Have person and pump evaluated• Restore intrathecal baclofen infusion

If ITB therapy is unavailable• Start high-dose oral baclofen• Use IV benzodiazepines as needed

Your physician will• Interrogate the pump status• Check x-rays of the pump and catheter

system• Perform a pump refill procedure• System troubleshooting procedures• If needed, surgical repair, revision or

replacement of system components.

Clinic Procedure taking about 20 minutes

Uses a handheld device placed on skin to program the pump

Sterile technique to access port • Needle inserted through skin to access port

reservoir• Remove any Medication left• Refill reservoir fully with liquid Baclofen.• Reprogram pump to desired dosing schedule

OK to go through metal detectors• May set off alarm – have ID card with you

OT to have CT scan OK to have MRI (must interrogate

pump afterwards) OK to continue stretching and

activities OK to be near household appliances OK to scuba-dive (up to 10 meters)

www. Va.gov/MS www.nationalmssociety.org www.msworld.org http://professional.medtronic.com/

therapies/intrathecal-baclofen-therapy-for-severe-spasticity/

www.webmd.com www.medicinenet.com