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Managing Spasticity with an Intrathecal Baclofen Pump

Kathleen Burgess, MD, MS

People living with MS can experience muscle stiffness, pain, jerking, weakness, or difficulty coordinating their movements. This is called spasticity. Spasticity is a disorder of the muscles and nerves commonly seen in people living with MS. Due to MS plaques in the brain and spinal cord, the body's normal ability to control muscle contractions and muscle relaxation is lost. Spasticity can be constant or come and go. Spasticity can be triggered by moving the limbs or irritation such as a wound or urinary tract infection. When spasticity is severe, it can limit a person's ability to walk, get dressed, complete personal hygiene, sit comfortably, or can cause pain.

How is spasticity treated?

There are many ways to treat spasticity and frequently multiple treatments are used at the same time. Daily stretching and strengthening is usually tried first for mild spasticity. Medications, such as baclofen, tizanidine, gabapentin, clonidine, dantrolene, or in some instances diazepam can be used. Botulinum toxin injections can be used when spasticity only affects a limited area such as one leg or arm. Bracing and surgery can also be used in certain cases. Delivering liquid baclofen into the spinal canal, called intrathecal baclofen (ITB), can also be used if other treatments are unsuccessful.

What is intrathecal baclofen (ITB) therapy?

ITB therapy is when liquid baclofen is delivered around the spinal cord. A small, round pump is surgically placed under the skin in the abdomen. A thin tube (catheter) attaches to the pump and goes around the abdomen to the back and is inserted into the spinal canal. Usually, you will be able to see and feel the pump. You will not be able to see or feel the catheter. The pump generally holds enough medication to last several months and is refilled in an office visit. The battery for the pump will last around seven years.

What are the benefits of ITB?

Medications used to treat spasticity can have side effects including dizziness, fatigue, or sleepiness. With ITB, since it is going directly to the spinal cord, it uses up to 100 times less medication to get the same effect. Additionally, the medication goes right to the spinal cord and may be more effective.

Who is the best candidate for ITB therapy?

The best candidates for ITB are people whose spasticity or spasms are not well controlled with other treatment options. They will need to be able to come in regularly for management of the pump. ITB therapy can be appropriate for people living with MS and should be considered if people are able to walk or are restricted to their bed. Goals of ITB therapy could include improving or maintaining the ability to walk, decreasing painful spasms, maintaining joint mobility, protecting the skin, doing personal hygiene activities, or making it easier to sit in a chair.

What is an ITB screening test?

Prior to getting a pump, most physicians will perform a screening test or refer you to a physician who does these tests. For the screening test, a dose of baclofen is injected into the spinal canal through a lumbar puncture, also called a spinal tap. You may have had this when you were diagnosed with MS. The test dose will give you and your doctor an idea if this medication is effective. This screening test may take place in a clinic or during a hospital admission.

During a positive response, the legs may become temporarily weak. This goes away usually in four to eight hours. During this time, you will be monitored by your doctor or physical therapist. They will monitor your blood pressure and heart rate, improvement in your symptoms, and note any negative side effects you may have. When the results of the medication fade, you will be sent home. Usually this is the same day. Rarely, you may have to spend the night in the hospital. The effects of the ITB therapy are not permanent. Although most doctors do a test dose to see if you are responsive to ITB, the test dose does not always predict exactly what it will be like with an ITB pump.

How is the pump implanted?

After the test dose, you and your doctor will decide if putting an intrathecal baclofen pump in surgically is right for you. The surgery will be scheduled for another admission and will be done by a surgeon who is familiar with this procedure. Most people are sent home the following day after the pump is implanted. Rarely, you may need to stay in the hospital for a couple of days while the dose is adjusted and you receive physical or occupational therapy.

What is done to manage the ITB pump after implantation?

After the pump is implanted, the dose will be non-invasively adjusted in your doctor’s office. Initially, this may be weekly to increase the pump dose and wean off oral spasticity medications. A stable dose is usually reached in several months. The daily dose can continue to be changed as needed. Depending on how much baclofen you use, your pump will need to be refilled every month to every six months. The pump has an alarm that will alert you if the pump runs out of medication or the battery is no longer functioning. Another surgery will be needed to replace the pump when the battery dies, or if there is a problem with the pump or catheter malfunctioning.

Severe consequences are rare but there is a chance of life threatening events such as getting too much baclofen (an overdose) or too little baclofen (withdrawal). Warning signs of an overdose can include drowsiness, lightheadedness, dizziness, difficulty breathing, seizures, lower than normal body temperature, or loss of consciousness. Warning signs of withdrawal can include increase or return of spasticity, itching, low blood pressure, lightheadedness, or a tingling sensation. If you have these symptoms, you will need to seek immediate care such as seeing your doctor or going to the emergency room.

Spasticity can have a significant negative effect on someone living with MS. An intrathecal baclofen pump is one method for treating spasticity. After the pump is in place, the best treatment for spasticity usually continues to include a variety of treatment options including daily stretching/strengthening, medications, bracing, or botulinum toxin injections.