A Qualitative Survey of Best Practices in Intrathecal Baclofen Therapy

Background: A qualitative survey was designed to summarize points of consensus and divergence related to best practices in intrathecal baclofen (ITB) therapy for severe spasticity.

Objectives: To provide clinical guidance leading to favorable long-term outcomes.

Methods: The panel consisted of 22 practitioners (20 physicians, 1 NP, 1 PT) practicing for a mean of 13 years (range 6-20 yrs), treating 23% pediatric vs. 77% adult patients primarily for cerebral palsy, cerebrovascular accident, MS, spinal cord or traumatic brain injuries.  

Results:

Patient Selection: An appropriate candidate for ITB has severe generalized spasticity that negatively impacts quality of life (e.g., function, movement, sleep, comfort). Nearly half of participants say a patient must have tried at least one oral therapy before ITB consideration. An unreliable patient with compliance issues should not be considered. Patient/caregiver education is vital.

Screening Test: This determines efficacy and previews pump effects for the patient/caregivers. During screening patients are monitored for spasticity, vital signs, functionality, symptomatic hypotension, tachycardia, or desaturation. Patients are referred to an implanter after positive screening, and pump size, catheter tip location, and starting dose communicated. Key measures include function (tone, strength, ROM, walking ability, stretching, Modified Ashworth Scores).

Dosing and Therapy Management: Dose titration is most often started in an inpatient setting, with length of stay lasting 2-5 days. ITB doses for adults range from 25-100 mcg, with dosing changes made according to response as patients are tapered off oral medications starting with baclofen. The optimal ITB dose allows the patient to reach pre-defined, individual therapy goals. Patient education is reinforced verbally and in writing.

Troubleshooting: Symptomatic patients (overdose or underdose) usually go to the ED or use oral baclofen and visit their doctor the next day. The Medtronic overdose/underdose algorithm is a key resource. First steps are an x-ray to check for catheter problems and trying a bolus dose. A careful patient history may also elicit non-pump problems. Acute underdose/withdrawal should be assessed in hospital where ITB withdrawal can be managed. Preop dose tapering precedes pump revision.

Participants encouraged strong collaboration in managing patient data (alarm dates, follow-up, diagnostic groups, dosages, outcomes), loss of efficacy and complications, and in reviewing protocols.

Conclusions: Participants recommended follow-up quantitative research to close information gaps and build on these findings.