christina a. hughes, md director, ms regional program va puget sound hcs
TRANSCRIPT
![Page 1: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/1.jpg)
Christina A. Hughes, MDDirector, MS Regional Program
VA Puget Sound HCS
![Page 2: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/2.jpg)
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
![Page 3: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/3.jpg)
Stretching and other modalities Oral medications
• Baclofen• Tizanidine• Clonazepam• Dantrolene• Valium• Gabapentin
Injections• Botulinum toxin• Phenol
Intrathecal Baclofen
![Page 4: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/4.jpg)
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
![Page 5: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/5.jpg)
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
![Page 6: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/6.jpg)
![Page 7: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/7.jpg)
![Page 8: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/8.jpg)
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
![Page 9: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/9.jpg)
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
![Page 10: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/10.jpg)
Requires General Anesthesia 1st incision – Lower Abdomen
• Create a pocket for pump beneath skin (above muscle layer)
2nd 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
![Page 11: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/11.jpg)
![Page 12: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/12.jpg)
Anesthesia risks Bleeding Infection Spinal Fluid leak Initial alteration in bladder control Initial alteration in spasticity control
requiring titration of intrathecal medication
![Page 13: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/13.jpg)
Pump Malfunction• Delivery of too much medication
Baclofen Overdose• Delivery of too little medication
Baclofen Withdrawal Catheter Malfunction
• Kinked catheter
![Page 14: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/14.jpg)
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
![Page 15: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/15.jpg)
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.
![Page 16: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/16.jpg)
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
![Page 17: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/17.jpg)
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.
![Page 18: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/18.jpg)
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
![Page 19: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/19.jpg)
![Page 20: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/20.jpg)
![Page 21: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/21.jpg)
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)
![Page 22: Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound HCS](https://reader036.vdocuments.net/reader036/viewer/2022070409/56649e965503460f94b9a07f/html5/thumbnails/22.jpg)
www. Va.gov/MS www.nationalmssociety.org www.msworld.org http://professional.medtronic.com/
therapies/intrathecal-baclofen-therapy-for-severe-spasticity/
www.webmd.com www.medicinenet.com