1. Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS

2.  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

3.  Stretching and other modalities  Oral medications Baclofen Tizanidine Clonazepam Dantrolene Valium Gabapentin  Injections Botulinum toxin Phenol  Intrathecal Baclofen

4.  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

5.  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

8.  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

9.  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

10.  Requires General Anesthesia  1 st incision – Lower Abdomen Create a pocket for pump beneath skin (above muscle layer)  2 nd 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

12.  Anesthesia risks  Bleeding  Infection  Spinal Fluid leak  Initial alteration in bladder control  Initial alteration in spasticity control requiring titration of intrathecal medication

13.  Pump Malfunction Delivery of too much medication  Baclofen Overdose Delivery of too little medication  Baclofen Withdrawal  Catheter Malfunction Kinked catheter

14.  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

15.  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.

16.  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

17.  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.

18.  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

21.  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)

22.  www. Va.gov/MS  www.nationalmssociety.org www.nationalmssociety.org  www.msworld.org www.msworld.org  http://professional.medtronic.com/thera pies/intrathecal-baclofen-therapy-for- severe-spasticity/  www.webmd.com www.webmd.com  www.medicinenet.com www.medicinenet.com