intrathecal baclofen: increasing patient functionality mary elizabeth s. nelson dnp, anp-bc nurse...
TRANSCRIPT
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