1. Intrathecal Baclofen: Increasing Patient Functionality Mary Elizabeth S. Nelson DNP, ANP-BC Nurse Practitioner, Milwaukee, WI.

2. 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

3. 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

4. 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.

5. 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

6. 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%

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Q&A time……  Questions?  Thank you!  Mary Elizabeth S. Nelson, DNP