Intrathecal Baclofen: Increasing Patient

Functionality

Mary Elizabeth S. NelsonDNP, ANP-BC

Nurse Practitioner, Milwaukee, WI.

A thorough evaluation is the key Core evaluation should be a combination of

subjective & objective spasticity assessments, strength and comorbid issues

Optional tools include Ashworth score, Tardieu scale, Spasm frequency scale, COPM, etc.

Formal PT and OT evaluations helpful Mandatory piece is goal setting to determine

spasticity impact on QOL and function

Focus on Goals Goal is NOT the elimination of spasticity Goal IS functional spasticity control Goal of surgery is to place device and heal

from surgery Setting realistic expectations is key to

patient satisfaction

Goals through the process Surgery: Place device and heal from

surgery Post op: Wean oral antispasmodics while

titrating dose Maintenance: Titrate dose to BALANCE

positive and negative symptoms Optimize outcomes; consider function,

position, ROM, hygiene, etc.

Dosing decisions Standard to start at 2x trial dose unless

trial dose caused loss of function due to weakness or dose lasted longer than 6-8 hours.

Adjust dose approximately 10-20% in clinic. Our max increase is 30%.

Some populations require miniscule changes (MS) and those that trial dose lasted greater than 6-8 hours

Should be able to duplicate trial response

Environmental considerations Dosing may be different inpatient vs.

outpatient Inpatient: Controlled environment, may

adjust as often as every 24 hours Outpatient: Rely on patients assessment,

may adjust weekly Ranges: Spinal: 10 – 30%. Cerebral 5 –

15% Pediatric 5 – 15% After 60 days label states Spinal 10 – 40%

and Cerebral 5 – 20%

Flex dosing considerations Most frequently add bolus dose when

patients can identify a time of day that they suffer from increased spasticity

Conversely will decrease dose during hours patient identifies as being too weak

“One change at a time” is a good rule to follow

Will consider Flex around 200 mcg/day if patients tone not adequately controlled

Additional considerations Idea of a bolus is to provide a “boost” of

drug. Run it as quickly as possible Advisable to start bolus dose no more than

20-30% of daily dose If patient tolerated a 50 mcg trial dose can

generally tolerate 50 mcg bolus Best to provide too small a dose than too

large and work dose up over time

Identification of problems Implant occurred after positive response to

trial dose, should be able to reproduce Systematic work-up is best practice to

identify system problems When developing an algorithm consider

plain films, side port access, dose ranges, dye studies, fluro/CT/Nuclear med access

Remember noxious stimuli Pain Infection Constipation Immobility Incisions Quick titration of

oral antispasmodic agents

UTI Pressure sores Addition of SSRI,

stimulants, diet medications and Betaseron

Anxiety

Don’t limit your treatment Wean oral medications and optimize pump If focal areas of spastic tone limit patient

include botulinum toxin injections in treatment MUST stretch and exercise a muscle that’s

been loosened PT, OT, ST, RT, Aquatic therapy, Hippo therapy Braces, Splints, Dynamic stretch Orthopedic surgery once spasticity treated Treatment of noxious stimuli and underlying

diseases

Additional thoughts When patients are anesthetized spasticity

is eliminated but contracture remains If tone altered to quickly can not adjust

into movement or strengthen underlying muscles quickly enough

Combination treatments may have synergistic effect

Different dosing patterns result in different responses, try delivering dose differently

Take away Goal is to improve patients Quality of Life Functional spasticity control! Wean oral antispasmodics to reduce side

effects Treat noxious stimuli and concurrent issues Stretch muscles and joints Optimize dosing to offer the greatest

benefit

Q&A time……

Questions?

Thank you!Mary Elizabeth S. Nelson, DNP