Spasticiteit en andere bewegingsstoornissen
Postgraduaat 27 januari 2009
Programma • Inleiding en Europese consensus voor de behandeling van spasticiteit bij volwassenen met intrathecale baclofen (ITB) • Drie casussen met ITB: – CVA – Familiale spastische paraparese – Dystonie (in kader van CP)
• Selectieve dorsale rhizotomie bij kinderen met hersenverlamming • Diepe hersenstimulatie bij bewegingsstoornissen
Spasticiteit, Lance 1980 • Stoornis van het sensorimotorisch systeem gekarakteriseerd door een snelheidsafhankelijke toename in tonische rekreflexen met verhoogde peesreflexen, t.g.v. de overprikkelbaarheid van de rekreflex, als onderdeel van het pyramidaal syndroom (CMN, UMN).
Fig. 1: The stretch reflex arc
Satkunam, L. E. CMAJ 2003;169:1173-1179
Copyright ©2003 Canadian Medical Association or its licensors
Consequences of spasticity • Positive aspects of spasticity1,2 – – – –
Maintain muscle tone and mass Can improve posture and aid sitting or transfers May help preserve bone density May help maintain circulation
• Negative aspects of spasticity – – – – – –
Abnormal movement and gait; positioning Care of the patient becomes more difficult Contractures Abnormal muscle and skeletal growth Pain Interferes with sleep
1. Meythaler JM. Phys Med Rehabil Clin N Am 2001;12:725-32. 2. Hinderer SR, et al. Phys Med Rehabil Clin N Am 2001;12:733-34.
ITB™: Intrathecale Toediening van Baclofen (Lioresal) Intrathecale toediening van baclofen
baclofen = spasmolyticum
analoog van de inhiberende neurotransmitter GABA-B
Behandeling van zware, resistente spasticiteit
oraal <--> intrathecaal
bloed-hersenbarrière
Indicatie ITB : aandoeningen van het centraal zenuwstelsel • Dwarslaesie • Niet-aangeboren hersenletsel – CVA, hersentrauma, …
• Hersenverlamming (CP) • Multiple sclerose • Neuromusculaire aandoeningen
Treatment algorithm (1) S
A P
S
ROM
ROM
C P
P
A
G N • I ROM • R
ADL IADL
• A
I
R
R
Treatment algorithm (2) N
F
O
L
S
N
M P
B D
A S
T
P I
I
C 3 6
S I
B
I C
6 8
I P
C
I
C 3 6
I P
I
Treatment algorithm (3) S G N A P P P
C N
I
C
O
P R A S
I
I N Q L
D B Q L
I
ITB
I 24 P B patients who rely on their spasticity when performing transfers —> L
Goals of spasticity management
“Low functional” level patients • Decrease spasticity • Decrease pain associated with spasticity • Reduce incidence of contractures • Improve hygiene • Improve transfers • Improve quality of life • Reduce cost of care and caregiver stress
Goals of spasticity management
“High functional” level patients • Decrease spasticity • Reduce pain • Improve functional ability and independence – Ability to manage activities of daily living
• Improve mobility, balance and endurance • Increase activity, participation and social involvement • Improve bladder control
Evidence for ITB Therapy • Evidence for ITB therapy analyzed in a health technology literature review – Level 2 evidence: ITB Therapy is effective in the short-term reduction of severe spasticity in patients with non-response to or intolerance of oral baclofen – Level-3 evidence: ITB Therapy is effective in the long-term reduction of severe spasticity in patients with non-response to or intolerance of oral baclofen – Level 4 qualitative evidence: ITB Therapy demonstrates functional improvement in patients with non-response to or intolerance of oral baclofen
Health Technology Literature Review (2005)
Inclusion and exclusion criteria Pre-selection criteria 1.Severe spasticity that reduces activity and participation (QoL) or causes pain, discomfort, difficulty with nursing care 2.Insufficient response to physical therapy and oral antispastic drugs, either as mono- or combination therapy 3.Absence of contraindications for baclofen based on pharmacological or psychological reasons 4.Patient’s informed consent 5.The need for continuing treatment and follow-up
Exclusion criteria Exclusion
Caution
Unrealistic goals
Seizures and epilepsy
Uncertain compliance (patient)
Deformity
Severe comorbidity
Other implanted system
Infection
Baclofen:
oraal versus intrathecaal Baclofen per os 100%
70-80% Uigescheiden met urine
30% bindt met proteïnen
27,3% plasma
2,7% CSF
Baclofen: oraal versus intrathecaal
Lioresal® Intrathecal 100%
95% CSF
5% Plasma
Intrathecal versus oral Daily Dose Administered
Resulting CSF Concentration
60.000
1,4 1,2
50.000
µg / milliliter
µg of Baclofen
60.000
40.000 30.000 20.000
1 0,8 0,6 0,4
10.000
600
0,2
0
Oral
Intrathecal
0
Oral
Intrathecal
Source: G. Ochs (1993), Kroin (1992), Kroin & Penn (1992), Penn, (1988)
Intrathecal drug delivery ¾
Intraspinal Catheter Pump
¾
Pump
Abdominal
Subfascial
Catheter Position
Tunneled subcutaneously from spinal cord to pump
Belgische Wetgeving: “baclofenpomp” •
Artikel 35 §1,C. Neurochirurgie. Verstrekking: 683071 – 683082
•
Programmeerbare implanteerbare elektronisch gestuurde pomp met regelbaar debiet, inclusief de programmeringshulpstukken, bestemd voor intrathecaal toedienen van een centraal werkend antispasmodicum bij zware resistente spasticiteit
§6. Wat de verstrekking 683071-683082 betreft: •
De verzekeringstegemoetkoming mag pas worden verleend voor de rechthebbende die lijdt aan een zware vorm van spasticiteit en die een testperiode van tenminste 5 dagen heeft ondergaan met positief resultaat
ITB™ - Testprocedure •
Test procedure • • • • •
•
Minimum 5 dagen screenen Via lumbaalpunctie of lumbale katheter Start op 25 of 50 µg bolus Indien onvoldoende respons: +25 µg na 24 uur Maximum (?) = 100 µg (tot 200 µg)
Definitieve implantatie SynchroMed pomp •
startdosis = testdosis indien respons min.12 uur , zoniet : dubbel van de testdosis
Evaluatie • Low functional – – – – –
MAS Verzorging Transfers Positionering Comfort
• High functional – – – – – –
MAS Gangpatroon Transfers Zitbalans ADL …
Post-implant rehabilitation • Rehabilitation goal: maximize benefits of ITB therapy (Romeiser Logan) • Whatever didn’t work before ITB, try again! – Orthotics – Dynamic splinting – Serial casting – Seating – Use of assistive technology – Therapeutic interventions
Overall treatment goals • Reduce – – – – – – –
Hypertonia Spasm Pain long term Dependence Burden of care Contracture Fatigue
• Improve – – – – – – – – –
Positioning Cosmesis Transfers Mobility (gait) (Independent) function Orthotic fit Muscle strength Endurance QoL
Post-implant rehabilitation • Bed rest (48 h?) • LMWH (2 w?) • Wound healing approximately 2 w – No immersion during 2w – No shower 3-5 d postop – Care with transfers (lift)
• Abdominal binder (2 w) ? – Not over chest ! – Only when upright
Post-implant rehabilitation • OT/PT – Gentle ROM of extremities allowed – No trunk rotation or extreme flexion (2-4w)
• After 2 (4-6 ?) weeks more agressive therapy
Post-implant rehabilitation • Education: what should the patient know? – Dosage – Alarm date (sound & significance of different alarms) – Symptoms of ITB withdrawal (& overdosage) – Management of ITB withdrawal (& overdosage) • Oral baclofen or prescription !!
– 24 h telephone contact
Titration of the drug • Monitor for : – Sedation – Orthostatic hypotension – Trunk weakness – Uninary retention – Constipation – Sexual function
• Simple continuous • SC with bolus • Flex
D
