Welcome to the TBI-HELP Live Chat

Today's topic is: "Intrathecal Treatment of Spasticity"

Our Guest is: Dr. Steven Flanagan,  
Director of Traumatic Brain Injury Clinic, Mt Sinai Medical Center


[19:01:25] Mod: Welcome to our professional moderated chat! Tonight we are very excited to have Dr. Steven Flanagan as our guest speaker. Dr. Flanagan is the Director of Traumatic Brain Injury Clinic at Mt. Sinai Medical Center. His topic tonight is Intrathecal Treatment os Spasticity. Welcome Dr. Flanagan!
[19:14:04] Mod: What is spasticity?
[19:15:48] Dr.Flanagan: Spasticity is an abnormality in muscle tone. When talking about muscle tone, it is not about the "tone" you strive for at a gym. Instead we are talking about the abnormal stiffness of muscles that occurs after an injury to the brain or to the spinal cord. By definition, spasticity means there is resistance to moving an arm or a leg. It can result in problems moving a limb, contractures, and difficulty walking or caring for yourself..
[19:19:03] Mod: Bruce: Why do some injuries to the brain produce flaccidity and some injurues produce spasticity?
[19:19:51] Dr.Flanagan: Initially after a brain injury, muscles become flaccid, that is , there is no resistance to passively moving a limb. As time goes on, however, flaccidity diminishes, and muscles become spastic..
[19:20:31] Mod: PattiSue: So few hospitals insert baclofen pumps. Is that a new procedure or just a very difficult protocol to set up?
[19:21:02] Dr.Flanagan: Intrathecal baclofen (ITB) has been available for several years. However, not many physicians are familiar with its use. It is not, however, a difficult program to initiate. All it involves is some training to the physician as well as interest in performing the test doses, programming and pump refilling..
[19:23:16] Mod: When using baclofen to reduce spasticity, aren't we also reducing mental acuity?
[19:24:03] Dr.Flanagan: The benefits of ITB are several. First of all, Baclofen works by interacting with nerve cells in the spinal cord. When you take baclofen by mouth, it is distributed to all parts of the body, requiring large doses. However, when you receive baclofen intrathecally, you require very small doses because it is being delivered to the one place where it works, that is the spinal cord. Therefore, you tend not to get tired or lethargic with ITB as you would if you took baclofen by mouth. Also, your physician can carefully titrate your dose to its maximum benefit while limiting side effects. The dose can be so well controlled with ITB that it becomes easier to avoid side effects while maintaining the beneficial effects..
[19:28:15] Mod: Guy: How else can you take baclofen? Is by mouth the only way?
[19:28:31] Dr.Flanagan: There are currently only two ways to take baclofen, by mouth and through the ITB system..
[19:29:06] Mod: PattiSue: What's the usual life of the battery that runs the pump?
[19:29:36] Dr.Flanagan: The battery typically lasts 5 to 7 years. The earlier models had batteries that lasted only 3 to 5 years, making it necessary to change pumps more frequently..
[19:30:22] Mod: Patty: When the pump is near empty, the patient seems to be more alert, with the appearance of emerging from a coma?
[19:31:14] Dr.Flanagan: If the pump is allowed to empty, there will be a return of spasticity. Also, if there has been some sedation as a result of the baclofen (which is typically less than if baclofen was given by mouth), you may feel more "awake"..
[19:31:45] Mod: Guy: What is ITB?
[19:32:07] Dr.Flanagan: ITB is a means to deliver baclofen directly to the part of the body where it works. It involves identifying people who the physician thinks will benefit from it. Typically, a person has spasticity which interferes with their ability to walk, position themselves, pr care for themselves. Also, their spasticity has not been responsive to other forms of treatment, typically therapy and other medications. The physician will perform a spinal tap on the person and give baclofen during the tap. Over the next 8 hours or so, the physician will monitor the change in spasticity to determine if it is effective. If it is effective, then the pump can be implanted. This involves a surgeon who places a pump, about the size of a hockey puck, into the abdomen. It is connect to a tube that is placed into the canal that contains the spinal cord. The pump is then programmed throughradio waves to deliver baclofen directly to the fluid that surrounds the spinal cord. Using this method, the overall dose of baclofen is dramatically reduced as compared to taking it by mouth..
[19:37:39] Mod: Bruce: Is Baclofen a unique drug in treatment of spasticity or are there alternatives?
[19:37:52] Dr.Flanagan: There are several methods to treat spasticity. Generally, simple measures are used, such as stretching an arm or leg  frequently throughout the day. This can be done by the person with the injury, their family members, therapists, etc. Sometimes heat or cold modalities are used. Usually, additional treatments are needed. These include medications. Some common medications include Zanaflex and Dantrium. Zanaflex is a relatively new medication. The major side effect is lethargy or feeling tired. Dantrium is a medication that works on the muscle directly rather than in the spinal cord. It is effective in some cases, but there is the potential for liver damage, particularly as individuals get a little older. It can also cause muscle weakness. Some doctors also use medications that are injected into the muscle, such as phenol or botox. These medications work by preventing nerve impulses reaching muscles which results in the "relaxation". Generally, these injections are better for small muscles and for spasticity that is not generalized to many places in the body. A decision needs to be made by the person with spasticity and their doctor regarding the need to treat spasticity.
[19:44:23] Mod: Please remember to check with your own physician before using medication. This is Dr. Flanagan's opinion and your own physician should be consulted prior using any medications.

[19:44:45] Mod: Guy: Should spasticity be treated or just left alone?
[19:44:45] Dr.Flanagan: Sometimes, spasticity is actually helpful to a person. For instance, if a person has a weak leg, their spasticity may actually be helpful for standing and walking. I know of casaes where the dose of baclofen needed to be reduced in order to allow spasticity to help a person to walk. So the decision to treat spasticity, and how much to reduce it is individualized to a person's needs.This is one of the valuable aspects of ITB. It allows for precise dosing which is not feasible when taking baclofen by mouth..
[19:48:29] Mod: PattiSue: Is the earlier this procedure is done the better to lessen the contracture
[19:49:11] Dr.Flanagan: The general guidelines state that you should wait one year after an injury before implanting the pump. I think that this may be too restrictive, particularly for the reason you stated. Spasticity frequently results in contractures, which is an inability to move a limb. If provided earlier than one year, you can frequently avoid contractures or at the very least, lessen there severity. Many clinicians use ITB prior to one year..
[19:51:36] Mod: Guy: Does the pump adjust itself?
[19:51:37] Dr.Flanagan: The pump does not adjust itself. It is completely reliant on the health care provider who refills it and programs it.. ITB is used in several neurological disorders.
[19:53:16] Mod: Bruce: Are there other neuromuscular disorders which may benefit from ITB aside from those related to TBI?
[19:53:43] Dr.Flanagan: The most frequent disorders in which it is used is TBI, spinal cord injury, multiple sclerosis and cerebral palsy. All of these conditions involve injury to the central nervous system. The central nervous system consists of those nerves that make up the brain and the spinal cord. Disease of nerves outside of the central nervous system so not cause spasticity..
[19:55:36] Mod: Are there lab tests to tell blood levels?Or is it based on flaccidity and spasticity?
[19:56:38] Dr.Flanagan: The determination of what does to give is based on the physician's examination as well as the report provided to the doctor form the person with the pump, the people taking care of them at home, and other health care providers, such as nurses and therapists. Blood tests are not used to determine the level of baclofen..
[19:57:26] Dr.Flanagan: Yes. [it based on flaccidity and spasticity]-added for clarity
[19:57:59] Mod: Patty: So if spasticity is lessened with a test dose the person is a good candidate for the pump?
[19:58:27] Dr.Flanagan: If the test dose was not effective, the physician should then give another test with a higher dose of medication..
[19:59:07] Mod: Bruce: Are there any contradictions with other co-prescribed medications?
[19:59:13] Dr.Flanagan: There are no absolute contraindications. However, it is probably unnecessary to keep people other anti-spasticity medications if they are on ITB treatment. also, it is generally a good idea to avoid other medications that make you tired, if that is possible..
[20:00:36] Mod: I see that our time is almost up. I'd like to thank the audience for providing excellent questions and I would like to thank Dr. Flanagan for a very informative session. Be safe and good night!
[20:01:33] Dr.Flanagan: Thank you for inviting me to this chat. The questions were all quite good and very well thought out!..