Spasticity Management in Neurological Conditions

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  • The upper motor neuron syndrome can be described as an insult that occurs to the higher levels of the central nervous system (i.e., brain, brain stem, or spinal cord). Essentially, this includes damage to everything but the anterior horn cell itself. This results in what has been termed positive and negative signs, with those signs in the positive category being in excess of the normal resting state, and those in the negative category being less than the normal resting state. Both positive and negative signs in this slide reflect abnormal findings in an upper motor neuron syndrome.
  • Although there is no definitive cause of spasticity, it is thought to be associated with an interruption of descending inhibitory nerve signals along the spinal cord and brain, which causes an imbalance between inhibition and excitation. [Point out the following on the slide] Descending inhibitory messages from the brain Upper motor neurons descend from the motor cortex of the brain to the spinal cord. Some of these neurons carry inhibitory messages. Lower motor neurons are the pathway from the spinal cord to the muscle fibers. Excitatory messages from the muscle Sensory pathways carry information, including excitatory messages, to the brain. Damage to the upper motor neuron pathways such as the reticulospinal, vestibulospinal, and rubrospinal tracts can result in a lack of inhibition, causing spasticity.
  • Assess whether hypertonicity is sustained or phasic, which occurs most commonly in the legs, especially at night. Patient assessment of spasticity should include a patient history interview to gain the following information: onset and evolution of spasticity severity of spasticity (mild, moderate, severe) presentation of spasticity (focal, segmental or global presentation) any triggers or patterns that set off spasms or spasticity any co-morbidities that contribute to or affect spasticity presentation current & previous spasticity management treatment intervention(s) (effectiveness of treatment, duration of effect, any side effects?) patient’s chief complaint(s) patient goals for spasticity treatment or intervention Additionally, deep tendon reflexes will be exaggerated, passive range of motion is often reduced, clonus may be present, and the therapist should assess how spasticity interferes with the patient’s function Note that there are several factors that can acutely increase spasticity such as UTI, infection, constipation, pain, stress, anxiety, etc.
  • A patient may have very little muscle strength but spasticity may assist in standing, ambulation and other movement that might not otherwise be possible. Positioning can trigger or inhibit spasticity and it is important to educate the patient in proper positioning to decrease spasticity and discomfort. Extreme spasticity can also lead to an increase in fatigue and energy consumption. It is important for the therapist to perform a full spasticity screening to determine whether or not spasticity is an advantage or detriment to a patient in a holistic approach. Determine whether spasticity contributes to a patient’s function and comfort or detracts from it. Overview: Spasticity in the MS patient is a treatable symptom that can dramatically improve a patient’s quality of life. There are several medical treatment options available today (oral medications, injection therapy, ITB therapy) that are used in combination with each other AND in conjunction with rehabilitation therapies that improve patient outcomes. Patients no longer have to suffer from spasticity. To maximize patient outcome, spasticity management should be an interdisciplinary, team process.
  • To treat or not to treat: Is spasticity preventing function? Is spasticity interfering with safety? Is spasticity causing pain? Is spasticity resulting in contractures? Is spasticity interfering with hygiene or sex? Goals of Rx: Decrease pain Prevent or decrease contractures Improve ambulating Facilitate ADLs Facilitate rehabilitation participation Save caregiver’s time and improve ease of care Increase safety
  • Oral Medications: Frequently the treating therapist is the one monitoring the effectiveness of the dose/dosing schedule. These oral medications have large side effect profiles. The most common complaint is lethargy and sedation. Injection Therapy includes (1) anesthetic/diagnostic nerve blocks (Lidocaine or Procaine), (2) Neuroltyic Procedures( Phenol/Ethanol), and (3) Botulinum Toxin (Botox ® ). Botulinum Toxin: is the most common type of injection therapy used currently, is injected directly into spastic muscles, it blocks acetylcholine from being released across the neuromuscular junction therefore weakening overactive muscle, peak effect occurs 7-10 days after injection, effects last shorter than Phenol injections but last approximately 3 months; re-injection can then be performed once every 3 months, muscle selection and the dose administered are important factors for success with Botulinum Toxin injections; therapists should provide input on muscle selection as is relates to how spasticity is interfering with functional performance and also provide the physician with input on the effect and duration of effect from previous injections – this assists the physician in adjusting the dose and muscle selection to optimize treatment plan and outcome. Nerve Blocks: reduce localized spasticity with neurochemical or neurotoxin on individual nerve.
  • (NOTE: Intrathecal and subarachnoid are synonymous terms) ITB is a site-specific, drug delivery system. The purpose of the pump is to deliver Baclofen directly to its site of action (laminae II & III of the spinal cord). For baclofen to reach its peak effect in reducing spasticity, it must get behind the blood brain barrier. The ITB Pump is a drug delivery system that delivers a liquid form of Baclofen directly into the cerbrospinal fluid (CSF) thereby bypassing the blood-brain barrier. This maximizes the drug effect of reducing spasticity while minimizing the side effects commonly seen with oral baclofen (lethargy, sedation, confusion, ataxia). ITB is most appropriate if spasticity causes pain or significantly interferes with function (moderate to severe spasticity), if more conservative treatment options have failed, and if the patient and family situation is reliable (needed for maintenance and refill of pump) and stable. ITB Therapy is not appropriate if spasticity is localized to 1 or 2 joints [i.e. wrist & hand] (or presents in one body part in a mild presentation), or if spasticity severity is caused by an exacerbating factor such as UTI, infection, stress, etc, or if patient is not medically stable to withstand pump implant procedure, or if patient has a history of allergy(hypersensitivity) to oral baclofen.
  • The pump minimizes the common side effects seen with oral baclofen (lethargy, sedation, confusion, ataxia) and maximizes the reduction in spasticity. ITB Therapy is the only spasticity management treatment option that can be titrated and programmed to meet each individual patient’s needs and clinical presentation. This is done by non-invasive programming through the pump programmer. (See next slide). This is important for MS patients as the pump can be programmed to meet fluctuating presentations during exacerbation and remission states and with progressing disease status. ITB Therapy received FDA approval for spinal origin spasticity (SCI & MS) in 1992 and for cerebral origin spasticity (BI, CVA, CP) in 1996. Today, there are more than 30,000 patients treated with ITB Therapy in the US. Approximately 30% of these patients have spasticity due to MS.
  • DESICCANT: used to absorb moisture in the electronics chamber to protect from corrosion and shorting ELECTRONIC HYBRID MODULE: this is the pump's brain, it controls the motor, the alarm, stores data, and talks to the external devices BULKHEAD: this is the pump's skeleton (fundamental structure) that all of the components are mounted into/onto PUMPHEAD: this is the actual pump (the motor turns the pumphead), it has three spring-loaded rollers that rotate around moving the trapped drug/fluid in the pump tubing out to the catheter
  • The ITB surgical procedure is non-destructive and reversible. Side effects of baclofen are usually eliminated or minimized via the titration process and much smaller doses are required by ITB administration than oral administration. (ITB is dosed in micrograms vs. oral baclofen in milligrams). Each patient’s optimal dose is PATIENT SPECIFIC. The dose will be titrated until the optimal dose is achieved. This can be changed at any time to meet the patient’s needs during periods of exacerbation, recovery, or disease progression. If pain is caused by spasticity, spasticity reduction often resolves this pain issue. Many patients can be weaned from pain medications as the direct cause of the patient’s pain is treated through spasticity management.
  • Loose muscles is a desired effect. However, excessive looseness is usually not a desired effect. Most side effects are managed via moving through the titration process in a gradual manner. If side effects continue to occur, it is common to decrease the dose and move through the titration process at a slower rate. Also, different pump programming options can be tried. Overdose (cause could be a programming error)can progress to a life-threatening event if not addressed. Common symptoms include excessive looseness (getting too much drug!), rostral progression of hypotonia (starts low in the body and moves towards the head), lethargy, respiratory depression,and decreased oxygen saturation level. Patient should be evaluated and treated immediately. Therapists should be aware of this and able to recognize the symptoms. Infection: same infection risk as any surgical procedure (~5%); patient should not resume aquatic therapy until completely healed and cleared by the physician
  • Withdrawal symptoms can occur from oral or intrathecal baclofen. ITB withdrawal can occur if the pump runs out of medication (i.e. patient did not attend refill appointment), the battery life of the pump runs out (listen for pump alarm and schedule replacement surgery prior to this date), or if there is a kink, hole, or blockage to the catheter. The pump system will be interrogated by the physician to determine the cause and corrected. Common symptoms of ITB withdrawal that the therapist should recognize are: increased spasticity(this may be beyond the patient’s baseline spasticity level), itching without a rash, and tingling/parasthesia sensations. Patient needs to see a physician immediately.
  • Spasticity Management in Neurological Conditions

    1. 1. Spasticity Management in Neurological Conditions A Quick-Start Guide George F. Wittenberg MD PhD 28 January 2010
    2. 2. Outline <ul><li>The Upper Motor Neuron Syndrome </li></ul><ul><li>Spasticity Management through Oral Medications </li></ul><ul><li>Spasticity Management through Parenteral Medications </li></ul><ul><ul><li>Botulinum Toxins </li></ul></ul><ul><ul><li>Intrathecal Baclofen </li></ul></ul><ul><li>Emergency Management </li></ul>
    3. 3. Upper Motor Neuron Syndrome <ul><li>Positive Signs (Excessive normal resting state) </li></ul><ul><ul><li>Spasticity </li></ul></ul><ul><ul><li>Rigidity </li></ul></ul><ul><ul><li>Hyperreflexia </li></ul></ul><ul><ul><li>Primitive reflexes </li></ul></ul><ul><ul><li>Clonus </li></ul></ul><ul><li>Negative Signs (Less than normal resting state) </li></ul><ul><ul><li>Lack of strength </li></ul></ul><ul><ul><li>Lack of motor control </li></ul></ul><ul><ul><li>Lack of coordination </li></ul></ul>Young RR, Emre M, Nance PW, et al. Current issues in spasticity management. Neurologist . 1997; 3:261-275. Young RR. Treatment of spastic paresis. N Engl J Med. June 1989;320(23):1553-1555.
    4. 4. Examples of UMN Lesions <ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Multiple Sclerosis </li></ul></ul><ul><ul><li>Corticobasal Ganglionic Degeneration </li></ul></ul><ul><ul><li>Traumatic Brain Injury </li></ul></ul><ul><ul><li>Acquired Brain Injury </li></ul></ul><ul><ul><li>Spinal Cord Injury </li></ul></ul><ul><ul><li>Cerebral Palsy </li></ul></ul>
    5. 5. Pathophysiology of Spasticity
    6. 6. Spasticity: Consequences <ul><li>Pain and discomfort </li></ul><ul><li>Contractures </li></ul><ul><li>Increased energy cost of movement </li></ul><ul><li>Skin breakdown–shear </li></ul><ul><li>Interferes with breathing </li></ul><ul><li>Hampers gait and transfers </li></ul><ul><li>Interferes with hygiene </li></ul><ul><li>More work for caregiver </li></ul><ul><li>Poor safety </li></ul><ul><li>Sexual difficulties </li></ul><ul><li>Insomnia </li></ul><ul><li>Poor posture </li></ul>
    7. 7. Spasticity: Assessment <ul><li>Patient report </li></ul><ul><li>Deep tendon reflexes </li></ul><ul><li>Passive range of motion </li></ul><ul><li>Test for clonus </li></ul><ul><li>Functional observation </li></ul><ul><ul><li>Determine nature of hypertonicity </li></ul></ul><ul><ul><li>Assess interference with function (gait) and effect of stress and/or fatigue </li></ul></ul><ul><ul><li>Assess adaptive shortening of muscles vs. irreversible contracture </li></ul></ul><ul><li>Consider aggravating factors (e.g., UTI, infection, excessive activity, strengthening exercises) </li></ul>
    8. 8. Modified Ashworth Scale <ul><li>0. No increase in muscle tone </li></ul><ul><li>(1) Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension. </li></ul><ul><li>(1+) Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement). </li></ul><ul><li>(2) More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved. </li></ul><ul><li>(3) Considerable increase in muscle tone passive, movement difficult. </li></ul><ul><li>(4) Affected part(s) rigid in flexion or extension. </li></ul><ul><li>(Original Ashworth score in parentheses; Modified after Bohannon and Smith Phys Ther. 1987 Feb;67(2):206-7. </li></ul>
    9. 9. Considerations in Reducing Spasticity <ul><li>Possible Advantages of Spasticity </li></ul><ul><ul><li>Maintains muscle tone/bulk </li></ul></ul><ul><ul><li>Helps support circulatory function </li></ul></ul><ul><ul><li>May prevent formation of deep vein blood thrombosis </li></ul></ul><ul><ul><li>May assist in activities of daily living </li></ul></ul><ul><ul><li>May assist with postural control </li></ul></ul>
    10. 10. Spasticity: Rehabilitation Intervention <ul><ul><li>Static stretch </li></ul></ul><ul><ul><li>Gait training (emphasis on swing and heel strike) </li></ul></ul><ul><ul><li>Positioning/posture </li></ul></ul><ul><ul><li>Cooling </li></ul></ul><ul><ul><li>Patient education </li></ul></ul><ul><ul><li>Relaxation </li></ul></ul><ul><ul><li>Bio-feedback </li></ul></ul><ul><ul><li>Reflex-inhibiting movement patterns </li></ul></ul><ul><ul><li>Avoiding noxious stimuli </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>ITB Therapy </li></ul></ul><ul><ul><li>Botulinum Toxin </li></ul></ul>
    11. 11. Spasticity: Medication <ul><li>Baclofen (Lioresal) </li></ul><ul><ul><li>GABA agonist </li></ul></ul><ul><ul><li>Max. dose 180 mg daily, divided </li></ul></ul><ul><ul><li>Side effects : sedation, incontinence, weakness, withdrawal seizures </li></ul></ul><ul><li>Tizanidine (Zanaflex) </li></ul><ul><ul><li>Alpha 2 adrenergic agonist </li></ul></ul><ul><ul><li>Max. dose 24-32 mg daily </li></ul></ul><ul><ul><li>Side effects : sedation, hypotension, weakness, hepatotoxicity </li></ul></ul><ul><li>Dantrolene - reserve for specialists </li></ul><ul><li>Diazepam et al. (Valium) </li></ul><ul><li>Gabapentin (Neurontin) </li></ul>
    12. 12. Considerations in Starting Oral Medications <ul><li>Titrate slowly: increase dose every five days, starting at: </li></ul><ul><ul><li>5 mg baclofen qHS </li></ul></ul><ul><ul><li>2 mg tizanidine qHS </li></ul></ul><ul><li>Inform patients to back off to previous dose if they encounter problems with sedation, other expected effects. </li></ul><ul><li>Effectiveness variable, often marginal </li></ul>
    13. 13. Spasticity: Invasive ℞ <ul><li>Botulinum Toxins A & B </li></ul><ul><li>Baclofen pump </li></ul><ul><ul><li>Intrathecal delivery via implanted pump (ITB) </li></ul></ul><ul><li>Surgical interventions </li></ul><ul><ul><li>Tenotomy (Tendon Lengthening) </li></ul></ul><ul><ul><li>Selective Rhizotomy </li></ul></ul>
    14. 14. Botulinum Toxins <ul><li>Derived from Clostridium botulinum bacteria </li></ul><ul><li>Multiple forms, but only A & B clinically approved </li></ul><ul><li>Produce reduction in muscle overactivity from 2-200 days after injection </li></ul><ul><ul><li>Peak effect begins 7-10 days after </li></ul></ul><ul><ul><li>Should not be reinjected before 90 days </li></ul></ul><ul><ul><li>May eventually become ineffective due to antibodies </li></ul></ul>
    15. 15. Injection Procedure <ul><li>Monitor with EMG (optional) </li></ul><ul><ul><li>Allows identification of muscles </li></ul></ul><ul><ul><li>Can help identify best targets </li></ul></ul><ul><li>Injected near motor points of muscles </li></ul><ul><li>Multiple injections per muscle </li></ul>
    16. 16. Common Spasticity syndromes treatable with Botulinum Toxin <ul><li>Thumb in palm – and clenched hand/flexed wrist in general </li></ul><ul><li>Elbow flexion </li></ul><ul><li>Striatal/ Clenched toes </li></ul><ul><li>Equinovarus deformity </li></ul><ul><li>Scissoring Gait </li></ul>
    17. 17. Side Effects of Botulinum Toxins <ul><li>Systemic Botulism </li></ul><ul><li>Respiratory compromise </li></ul><ul><li>Dysphagia </li></ul><ul><li>Dry mouth </li></ul><ul><li>Muscle Pain </li></ul><ul><li>Weakness </li></ul>
    18. 18. Response Problems <ul><li>Poor response may be primary (with first injection) or secondary </li></ul><ul><li>Reasons for poor response </li></ul><ul><ul><li>Poor muscle injection technique </li></ul></ul><ul><ul><li>Incorrenct muscle selection </li></ul></ul><ul><ul><li>Dosing inadequate </li></ul></ul><ul><ul><li>Muscle involvement has changed </li></ul></ul><ul><ul><li>Soft tissue contracture </li></ul></ul><ul><li>Neutralizing antibodies may be present (but rare in spasticity) </li></ul><ul><ul><li>Tests for nonresponse: frontalis test, </li></ul></ul><ul><ul><li>antibody assays (limited sensitivity, specificity) </li></ul></ul>
    19. 19. Dosing of Botulinum Toxin <ul><li>Botox (onabotulinumtoxinA) available in 100 unit vials of lyophilized powder </li></ul><ul><ul><li>Max dose not established, but FDA warns against dosing more than 400 units </li></ul></ul><ul><li>MyoBloc (rimabotulinumtoxinB) units are about 50x less potent than Botox </li></ul><ul><li>So 100 units Botox are approximately equivalent to 5000 units MyoBloc </li></ul>
    20. 20. ITB Therapy <ul><li>Intrathecal Baclofen Therapy delivers liquid baclofen directly into the intrathecal space around the spinal cord </li></ul><ul><li>Drug delivered via an implanted and programmable pump connected to a catheter </li></ul><ul><li>Approved by FDA in 1992 for spinal origin spasticity and 1996 for cerebral origin spasticity. </li></ul><ul><ul><li>Components are completely implanted (except the programmer) </li></ul></ul><ul><ul><li>Programmer is used to adjust the pump. </li></ul></ul><ul><ul><li>Implanting the pump is the beginning of therapy, takes 30-90 days to adjust dosage </li></ul></ul>
    21. 21. SynchroMed II Pump
    22. 22. Pump Compatibility <ul><li>The following are unlikely to affect pump operation or damage the pump: </li></ul><ul><ul><li>Electrocautery </li></ul></ul><ul><ul><li>Diagnostic Ultrasound </li></ul></ul><ul><ul><li>Low-Power Therapeutic Ultrasound – i.e. the type used in P.T. </li></ul></ul><ul><ul><li>Pacemakers/ICD’s </li></ul></ul><ul><ul><li>Diagnostic X-rays </li></ul></ul><ul><ul><li>TENS </li></ul></ul><ul><ul><li>Laser Procedures </li></ul></ul><ul><ul><li>Pressurized Aircraft </li></ul></ul><ul><ul><li>Theft detectors/Security Devices </li></ul></ul><ul><ul><li>Home Appliances </li></ul></ul><ul><ul><li>Tanning Bed </li></ul></ul>
    23. 23. Advantages of ITB ℞ <ul><li>Non-destructive and reversible </li></ul><ul><li>Potential for fewer side effects as compared to oral baclofen </li></ul><ul><li>Dose can be adjusted to optimal effect </li></ul><ul><li>May decrease spasticity-related pain </li></ul>
    24. 24. Potential Risks of ITB ℞ <ul><li>Most common side effects: weakness, drowsiness, nausea/vomiting, headache, and dizziness </li></ul><ul><li>Overdose, although rare, could lead to respiratory depression, loss of consciousness, coma, and in extreme cases, may be life-threatening </li></ul><ul><li>Infection </li></ul>
    25. 25. Potential Risks of ITB ℞ <ul><li>Abrupt discontinuation can result in high fever, altered mental status, worsened spasticity, and muscle rigidity </li></ul><ul><ul><li>needs to be treated as life threatening </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><li>Empty pump reservoir </li></ul></ul><ul><ul><li>Catheter failure: disconnecting from pump, kinking, migrating or breaking </li></ul></ul><ul><ul><li>Electromechanical failure, e.g. battery failure </li></ul></ul>
    26. 26. Management Issues: Spasticity has increased <ul><ul><li>Patient not getting enough drug </li></ul></ul><ul><ul><ul><li>Low reservoir </li></ul></ul></ul><ul><ul><ul><li>Programming/refill error </li></ul></ul></ul><ul><ul><ul><li>Pump or catheter problem </li></ul></ul></ul><ul><ul><li>Factor causing increase in spasticity </li></ul></ul><ul><ul><ul><li>Disease progression </li></ul></ul></ul><ul><ul><ul><li>Physiologic response </li></ul></ul></ul>
    27. 27. Management Issues: Spasticity has decreased – hypotonia <ul><ul><li>Patient getting too much drug </li></ul></ul><ul><ul><ul><li>Programming error </li></ul></ul></ul><ul><ul><ul><li>Refill error </li></ul></ul></ul><ul><ul><ul><li>Subdural catheter </li></ul></ul></ul><ul><ul><ul><li>Pump pocket injection </li></ul></ul></ul><ul><ul><ul><li>Oral medication </li></ul></ul></ul>
    28. 28. Management Issues: Altered Mental Status <ul><li>Altered mental status </li></ul><ul><ul><li>Could be sign of overdose or withdrawal </li></ul></ul><ul><ul><ul><li>Has spasticity increased or decreased? </li></ul></ul></ul><ul><ul><ul><li>Other associated symptoms </li></ul></ul></ul>
    29. 29. Circumstances That May Require Added Attention <ul><li>Higher ITB Therapy doses </li></ul><ul><li>Non-verbal patient </li></ul><ul><li>Inability to identify problem/localize pain </li></ul><ul><li>ITB Therapy naïve medical system </li></ul><ul><ul><li>ER/ICU doesn’t contact “pump doctor” until after cascade effect </li></ul></ul><ul><li>After pump replacement </li></ul><ul><li>After pump removal for infection </li></ul>
    30. 30. Lioresal Intrathecal <ul><li>Lioresal Intrathecal is an analog to the naturally occurring inhibitory neurotransmitter gamma-aminobutyric acid (GABA) </li></ul><ul><ul><li>Effects similar to benzodiazepines </li></ul></ul><ul><li>SynchroMed ® II pump reservoir holds 20 or 40 ml of drug </li></ul><ul><ul><li>6-month supply </li></ul></ul><ul><ul><ul><li>500 mcg/ml </li></ul></ul></ul><ul><ul><ul><li>2000 mcg/ml </li></ul></ul></ul>
    31. 31. Overdose <ul><li>Symptoms Are Dose-Dependent </li></ul><ul><ul><li>Mild </li></ul></ul><ul><ul><ul><li>Hypotonia </li></ul></ul></ul><ul><ul><ul><li>Difficulty concentrating </li></ul></ul></ul><ul><ul><ul><li>Progressive decrease in tone to flaccid </li></ul></ul></ul><ul><ul><li>Moderate </li></ul></ul><ul><ul><ul><li>Somnolence </li></ul></ul></ul><ul><ul><ul><li>Obtundation </li></ul></ul></ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><ul><li>Stupor </li></ul></ul></ul><ul><ul><ul><li>Hypoventilation to apnea </li></ul></ul></ul><ul><ul><ul><li>Coma </li></ul></ul></ul>
    32. 32. Overdose <ul><li>Iatrogenic </li></ul><ul><ul><li>Likely due to human error </li></ul></ul><ul><ul><li>Programming error </li></ul></ul><ul><ul><li>Unanticipated effect of dosage or concentration </li></ul></ul><ul><li>SynchroMed pump vs. catheter malfunction </li></ul><ul><li>Difficult to ascertain cause </li></ul>
    33. 33. Overdose – Mechanical Causes <ul><li>Subdural catheter </li></ul><ul><li>Filling of pump pocket </li></ul><ul><ul><li>18 ml of Lioresal Intrathecal 500 mcg/ml=9 mg </li></ul></ul><ul><ul><li>18 ml of Lioresal Intrathecal 2000 mcg/ml=36 mg </li></ul></ul><ul><ul><li>40 ml of Lioresal Intrathecal 500 mcg/ml=20 mg </li></ul></ul><ul><ul><li>40 ml of Lioresal Intrathecal 2000 mcg/ml=80 mg </li></ul></ul>
    34. 34. Overdose - Treatment <ul><li>Suggested Treatments </li></ul><ul><li>Mild </li></ul><ul><ul><li>Decrease dose </li></ul></ul><ul><li>Moderate </li></ul><ul><ul><li>Stop pump for several hours (2-4 hours) </li></ul></ul><ul><ul><ul><li>Program minimal infusion bolus, then restart at lower dose </li></ul></ul></ul><ul><ul><li>Decrease dose </li></ul></ul><ul><li>Monitor patient carefully for at least 24 hours </li></ul>
    35. 35. Severe Overdose <ul><li>Suggested Treatment </li></ul><ul><li>Maintain airway/breathing/circulation </li></ul><ul><li>Empty pump reservoir to stop drug flow </li></ul><ul><ul><li>Aspirate reservoir if no programmer </li></ul></ul><ul><ul><li>Remember to schedule restart </li></ul></ul><ul><li>Administer physostigmine/pressors </li></ul><ul><ul><li>+/- physostigmine(0.5-1.0mg increments IV) </li></ul></ul><ul><li>LP to withdraw 30 – 40 mL CSF </li></ul><ul><li>Notify patient's ITB Therapy physician </li></ul><ul><li>Continue to monitor closely for symptom recurrence </li></ul>
    36. 36. Suggested Treatment <ul><li>Remove CSF </li></ul><ul><ul><li>An effective treatment </li></ul></ul><ul><ul><ul><li>Effective in first 4 hours </li></ul></ul></ul><ul><ul><ul><li>Still may be effective up to 8 hours </li></ul></ul></ul><ul><ul><li>Catheter access port (CAP) </li></ul></ul><ul><ul><li>30 – 40 mL </li></ul></ul><ul><ul><li>Lumbar puncture if cannot aspirate CAP </li></ul></ul>
    37. 37. Sequelae of Severe Overdose <ul><li>Patient </li></ul><ul><ul><li>Less frequent if airway is protected and hypotension treated rapidly </li></ul></ul><ul><li>Family </li></ul><ul><ul><li>Fear of patient’s death </li></ul></ul><ul><ul><li>Fear of brain damage </li></ul></ul><ul><ul><li>Intensive emotional support needed </li></ul></ul>
    38. 38. Baclofen Withdrawal <ul><li>Severity of withdrawal varies </li></ul><ul><ul><li>Mild </li></ul></ul><ul><ul><ul><li>Minimal symptoms </li></ul></ul></ul><ul><ul><ul><li>Mild flu-like syndrome </li></ul></ul></ul><ul><ul><li>Moderate </li></ul></ul><ul><ul><ul><li>Increase in tone </li></ul></ul></ul><ul><ul><ul><li>Itching </li></ul></ul></ul><ul><ul><ul><li>Mild dysphoria </li></ul></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><ul><li>Continuous spasms </li></ul></ul></ul><ul><ul><ul><li>Severe pain </li></ul></ul></ul><ul><ul><ul><li>Delirium </li></ul></ul></ul><ul><ul><ul><li>Death </li></ul></ul></ul>
    39. 39. Symptoms of Underdose <ul><li>Pruritis without rash </li></ul><ul><li>Hypotension </li></ul><ul><li>Paresthesias </li></ul><ul><li>Fever </li></ul><ul><li>Altered mental status </li></ul>
    40. 40. Symptoms of Withdrawal <ul><li>Exaggerated rebound spasticity and muscle rigidity </li></ul><ul><li>Might be diagnosed in ER as seizures </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><li>Multiple organ failure </li></ul><ul><li>May resemble </li></ul><ul><li>Autonomic dysreflexia </li></ul><ul><li>Sepsis </li></ul><ul><li>Malignant hyperthermia </li></ul><ul><li>Neuroleptic-malignant syndrome </li></ul>
    41. 41. Suggested Treatment <ul><li>Always assume it’s the Intrathecal Baclofen </li></ul><ul><li>Initiate life-sustaining measures if indicated </li></ul><ul><li>Thorough history </li></ul><ul><ul><li>Abrupt vs insidious onset </li></ul></ul><ul><ul><li>Presence of VPS </li></ul></ul><ul><ul><li>Recent refill/replacement/programming </li></ul></ul><ul><li>Start oral baclofen </li></ul><ul><ul><li>Each patient needs prescription at home </li></ul></ul><ul><ul><li>Remind family to take prescription on vacation </li></ul></ul>
    42. 42. Other Interventions <ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><ul><li>GABA agonists </li></ul></ul></ul><ul><ul><ul><li>IV or PO </li></ul></ul></ul><ul><ul><li>Cyproheptadine (serotonin antagonist)* </li></ul></ul><ul><ul><ul><li>Cyproheptadine 4-8 mg every 6 hours </li></ul></ul></ul><ul><ul><li>Lioresal Intrathecal via LP </li></ul></ul><ul><ul><ul><li>50-100 mcg bolus </li></ul></ul></ul><ul><ul><li>Lumbar infusion via bedside pump and percutaneous catheter </li></ul></ul><ul><ul><ul><li>Maintenance </li></ul></ul></ul><ul><ul><ul><li>Weaning ITB Therapy </li></ul></ul></ul><ul><li>*Meythaler JM, Roper JF, Brunner RC. Cyproheptadine for intrathecal baclofen withdrawal. Arch Phys Med Rehabil 2003; 84:638-642. </li></ul>
    43. 43. Pearls to Prevent Withdrawal <ul><li>Refill pump if suspect low reservoir </li></ul><ul><li>Compare actual vs expected aspirate </li></ul><ul><li>Verify concentration of last refill </li></ul><ul><li>Systems to ensure patients receive refills in a timely manner </li></ul><ul><li>Examine programming after pump replacement </li></ul><ul><li>Troubleshoot pump and catheter immediately upon suspicion of malfunction </li></ul><ul><li>Patients should have some oral baclofen available for emergency </li></ul>
    44. 44. Conclusions <ul><li>While spasticity management can be difficult, it may also improve patient’s quality of lift </li></ul><ul><li>Spasticity is not necessarily the enemy, but is part of a pattern of abnormal motor control </li></ul><ul><li>Choice of treatment depends on pattern of involvement </li></ul>
    45. 45. Contact <ul><li>For questions about this audio conference please contact Dr. George Wittenberg at george.wittenberg@va.gov </li></ul><ul><li>For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328 </li></ul><ul><li>To evaluate this conference for CE credit please obtain a ‘Satellite Registration’ form and a ‘Faculty Evaluation’ form from the Satellite Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcast </li></ul>

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