ABSTRACT
INTRODUCTION: When spasticity interferes with comfort, function, activities of daily living, mobility, positioning, or caregiver assistance, patients should be considered for intrathecal baclofen (ITB) therapy. METHODS: An expert panel consulted on best practices. RESULTS: ITB can be considered for problematic spasticity involving muscles/muscle groups during all phases of diseases, including progressive neurologic diseases. ITB alone or with other treatments should not be exclusively reserved for individuals who have failed other approaches. ITB combined with rehabilitation can be effective in certain ambulatory patients. ITB is also highly effective in managing spasticity in children, who may suffer limb deformity, joint dislocation, and poor motor function from spasticity and muscle tightness on the growing musculoskeletal system. Spasticity management often allows individuals to achieve higher function. When cognition is impaired, ITB controls spasticity without the cognitive side effects of some oral medications. Goal setting addresses expectations and treatment in the framework of pathology, impairment, and disability. ITB is contraindicated in patients with hypersensitivity to baclofen, which is rare, or active infection. Some patients with an adverse reaction to oral baclofen may be mistakenly classified as having an allergic reaction and may benefit from ITB. Relative contraindications include unrealistic goals, unmanageable mental health issues, psychosocial factors affecting compliance, and financial burden. Vascular shunting for hydrocephalus is not a contraindication, but concurrent use may affect cerebrospinal fluid flow. Seizures or prior abdominal or pelvic surgery should be discussed before proceeding to an ITB screening test. CONCLUSIONS: ITB should be considered when spasticity interferes with comfort or function.
Subject(s)
Baclofen/administration & dosage , Muscle Relaxants, Central/administration & dosage , Muscle Spasticity/drug therapy , Patient Selection , Practice Guidelines as Topic/standards , Databases, Bibliographic/statistics & numerical data , Humans , Injections, Spinal , Time FactorsABSTRACT
Dose stabilization of intrathecal baclofen (ITB) is usually achieved within 6 to 18 months. In some patients, an increase in ITB dose may result in paradoxical unresponsiveness to baclofen. We present two cases demonstrating increased tone and functional decline with increasing ITB doses after a period of clinical stability. In both cases, reduction of ITB dose was associated with marked clinical improvement.
Subject(s)
Baclofen/administration & dosage , Hemiplegia/drug therapy , Hemiplegia/physiopathology , Muscle Relaxants, Central/administration & dosage , Quadriplegia/drug therapy , Quadriplegia/physiopathology , Adult , Analgesics/therapeutic use , Anticonvulsants/therapeutic use , Baclofen/therapeutic use , Dose-Response Relationship, Drug , Drug Resistance , Drug Therapy, Combination , Humans , Injections, Spinal , Male , Muscle Relaxants, Central/therapeutic use , Pain/physiopathology , Treatment OutcomeABSTRACT
Intrathecal baclofen (ITB) is a recognized therapy for severe spasticity of both spinal and cerebral origin, with documented positive clinical outcomes for many patients with multiple sclerosis (MS). This article reviews some specific considerations concerning the use of ITB in the MS population, based on the author's 10 years of clinical experience. The unpredictable and progressive nature of the disease affects the identification of appropriate goals, the patient's decision-making process, and the evaluation of the response to the treatment over time. Patients with MS may be more sensitive to intrathecal baclofen than patients with other diagnoses, and may need a lower dose for both the screening test and maintenance therapy. Subtle cognitive changes may affect the patient's ability to understand the education needed for successful management of ITB. Some practical strategies are offered for the nurse involved in the care of these patients in each stage of the therapy.
Subject(s)
Baclofen/therapeutic use , Multiple Sclerosis/therapy , Muscle Relaxants, Central/therapeutic use , Activities of Daily Living , Attitude to Health , Baclofen/adverse effects , Cognition Disorders/etiology , Cognition Disorders/prevention & control , Decision Making , Disease Progression , Drug Administration Schedule , Drug Monitoring , Health Services Needs and Demand , Humans , Infusion Pumps, Implantable , Injections, Spinal , Mass Screening , Mental Competency , Multiple Sclerosis/complications , Multiple Sclerosis/psychology , Muscle Relaxants, Central/adverse effects , Nurse's Role , Nurse-Patient Relations , Nursing Assessment , Patient Care Planning , Patient Selection , Perioperative Care/methods , Perioperative Care/nursing , Rehabilitation Nursing , Treatment OutcomeABSTRACT
Practitioners from around the country who have extensive experience in intrathecal baclofen (ITB) therapy gathered in early 2004 to develop best-practice guidelines for ITB therapy. Discussion focused on the idea that ITB therapy is a program rather than a procedure. Key recommendations were made in areas including team coordination, patient selection and goals, patient education, patient screening, implant technique, long-term management, individualized dosing options, ongoing evaluation of patient response, appraisal of the integrity of the catheter and infusion system, and appropriate practice resources.
