Spasticity Management: Long term follow up- a team ... - acpin

Spasticity Management:Long term follow up- a teamapproachLiz KeenanClinical nurse specialist in Spasticity Management,NHNNWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Optimal managementApproach needs to be:MultidisciplinaryHolisticCoordinated– Clinical governance, Protocol, Telephone help lineTailored to the individualTimelyWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Long term follow up forIntrathecal Baclofen (ITB)Pump battery life is between 5-757 yearsBaclofen stability 180 daysRoutine refill every 6/12Post implants more frequent visits as doseis being ‘fine tuned’Wessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Holistic review every 6 monthsAssessment– General health– Trigger/ aggravating factorsEfficacy– Goal attainment, outcome measures, joint therapyreviewRefill procedureSpecial circumstances– Changing dose, concentration, MRI, Dye tests– Trouble shootingWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

General reviewAny new problems– With underlying condition– With spasticity, pain, spasms– With treatment (side effects, reduced efficacy)Review current anti-spasticity treatmentWeight, dentitionTrigger factorsWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Triggers and noxious stimuliSkinSplintsOrthoticsBladderBowelsPain, skinWessex ACPIN Spasticity Presentation 2009. © Liz KeenanSeating & positioning

Assessment-Hands OnObserve- posture, movement andalignmentObserving - GaitFeel resistance to passivemovementDetermine biomechanicalcomponentAssess underlying weaknessWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

MeasuresReview goal attainmentTone - AshworthRange of movement – GoniometryTimed functional tasks, 10m walkDisease specific scales eg. MSSS-88Carer ratings for ease of careWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

MeasuresSpasm scale - (Pennet al 1989)Visual analogues ofpain, comfort, legstiffnessConsider therapyreview at leastannuallyWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

In Practice24yr man with CP, receiving ITB for 6 years,independently mobile however had reportedfalling over the last few months– Moved to UK from USA– Dose had been changed for years– Booked to have assessment with PT– All measures completed– Recommendation to reduce dose 10%Wessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Physical management of spasticityCONSIDERStandingActiveexerciseBalancebetweenmovementandpositioningFunctionalelectricalstimulationWheelchairpostureand seatingPassivemovementStretchesSplintingand theuse oforthoticsWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

In Practice65yr man with MS, receiving ITB for 15 years– His wife called help line reporting increase in spasms,but only at night– Booked to have joint assessment PT / CNS– Ax in lying and seating and all measures completed– RecommendationAdvice given on physical management strategies– Side lying– Using profile element of bed– Seating alignment– Bladder and skin careWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

In practice:community physiotherapistLinking with community teamTIMEPerson with spasticity and their PT assessingfunction in home environmentFeed back to spasticity team (eg ITB)Wessex ACPIN Spasticity Presentation 2009. © Liz Keenan

ITB Refill clinicExamine pump site examine skin andobserve for any signs of infection (brokenskin, tenderness and redness)Wessex ACPIN Spasticity Presentation 2009. © Liz Keenan

TelemetryRead pumpCheck;– Patient data– Baclofen concentration– Dose– Dosing schedule– Reservoir volume– Volume drug remaining– Alarms enabledWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Data storedCritical therapy data stored in pump forfollow up at any recognised centre– Patient demographics– Pump implant information– Catheter : type, length / volume– Implant/Revision HistoryNotesWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Position for refillNo special requirementsTilt in space slightly tilted back for ease ofaccess.LyingWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Refill kit equipmentWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Refill procedureAsceptic techniqueRefill kitLocate central reservoir portNot catheter access portEmpty pump and checkvolume removed appropriateRefill pump with appropriateconcentration and volumeWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Refill procedureWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

ReprogrammingChange reservoir volumeMake any dose or dosagescheduling changesCheck with 2 people;– Patient data– Baclofen concentration– Dose– Dosing schedule– Reservoir volume– Alarms enabled– Low reservoir alarm datePrint copies for notes andpatient held recordsWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Principles of titrationChange one thing at a timeDo not change oral until getting a responsefrom ITBIncrease (10% - 20%)Review spasticity in context of:Function at home and workAgreed GoalPrevious measuresOral medicationNo magic titration formulaWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Infusion ModesvolumetimeSimple continuousvolumetimeSingle bolus +Simple continuousvolumetime“Flex” modevolumeWessex ACPIN Spasticity Presentation 2009. © Liz KeenantimeMinimum rate

Careful considerationChanging the Baclofen concentrationComplications with the pump and catheterDye studyMRIWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Changing Baclofen concentrationCaution is needed to prevent accidental overdosePerform telemetryEmpty the pump completely checking the expectedreservoir volumeRinse the reservoir twice with normal salineFill the pump with the new concentration solution– Usually 500-3000mcg/mlReprogramme the pump with the new parameters(reservoir volume, concentration and any change in dose)Perform a bridging bolusCheck all parameters with a colleagueWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Change of concentrationInternal PumpTubingCatheterDRUGPumpReservoirA Bridge bolus needto be completedWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Catheter-Related ComplicationsKinking, disconnectionMicro-tearComplete or partial occlusionDislodgement or migrationFibrosisDetached catheter tip or catheter fragment(s) inthe intrathecal spaceWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

SynchroMed II PumpMechanicsWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Pump RefillWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Dye StudiesCaution is needed to prevent accidental overdosePerform telemetry and stop pumpAsceptic technique in RadiologyUse catheter port access kit and locate catheter portAspirate at least 2mlsIf unable to aspirate stop procedure- do not attempt to flushInject radiopaque dye and perform fluroscopyIf resuming ITB restart pump and perform a catheterpriming bolus (catheter volume only, not internal tubing)Check all parameters with a colleagueWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Post dye studyInternal PumpTubingDRUGCatheterPumpReservoirDRUGIf resuming ITB restart pumpand perform a catheter primingbolus (catheter volume only,not internal tubing)Check all parameters with acolleagueWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

MRICheck with senior radiologist and pump manufacturerScanning time may be increased due to metallic pump andartefact possibleAll rotar arm motorised pumps (Medtronic) will suspend drugdelivery during scanAlways perform telemetry 30 mins after imagingFollow manufacturer’s s instructions to ensure pump log showsmotor stall and recoveryCheck all parameters with a colleagueWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Help lineTelephone help lineContinuity of care and access whennecessaryOut of hours link to a NeurorehabilationUnit which takes call, completing atemplate so accurate information isgatheredWessex ACPIN Spasticity Presentation 2009. © Liz Keenan

Ongoing managementManagement continues every 6 monthsTitration continues with 10%-20% intervals of increaseContinue to have regular phone contactRecent discussion with patient she expressed that shewas very happy that her spasms and spasticity had gonebut it has made her ‘face‘ her disability which wascompounded by a longstanding low mood, however“having more comfort, less pain and spasms I get abetter nights sleep, so I feels more prepared to makechanges in my life”.Wessex ACPIN Spasticity Presentation 2009. © Liz Keenan

ReferencesDarzi Report (2008) High Quality Care For All: NSR final reportlaunched. National Health Service, Department of Health.LondonDepartment of Health (2005) National Service Framework forLong-Term Conditions. The Stationery Office, LondonJarrett L (2006) The nurse's role in assessing and measuringspasticity. Nursing Times; 102: 26-8Penn RD, Savoy SM, Corcos D et al. (1988) Intrathecal baclofenfor severe spinal spasticity. N Engl J Med;320:1517–21.21.Stevenson V, Jarrett L (2006) Spasticity Management: APractical Multidisciplinary Guide. Informa Health Care, OxfordThompson AJ, Jarrett L, Lockley L, Marsden, J and StevensonV (2005) Clinical management of spasticity. Journal of J NeurolNeurosurg Psychiatry; 76: 459-463463Welmer A-K, Avon Arbin M, Widen Holmqvist L, SommerfeldDK ( 2006) Spasticity and its association with functioning andhealth –related quality of life 18 months after stroke.Wessex ACPIN Spasticity Presentation 2009. © Liz KeenanCerebrovascular Disease; 21:247-253253