• Ensure patient selection criteria are met.
• Admit to short care facility, ASU, ICU.
• Score pre-trial spasticity.
• Administer baclofen intrathecally.
• Monitor hourly for adverse effects.
• Score post-trial spasticity @ 2, 4, and 6 hours.
• Positive responders -> implantation.

Pre-Screening: Nursing Involvement

• Call patient / caregiver prior to test dose trial
• Assess needs: specialty beds, equipment, tube feeding, wound care, medication, special needs, etc.
• interview staff or family as to patients limitations, contracture, pain, functionality
  

Pre-Screening: Nursing Educates

Day of ITB Screening Trial

• Early AM admission
• Labs (CBC, BMP, PT, PTT), EKG’s, IV access @ bedside
• Monitors: BP, Pulse Ox, Cardiac Rhythm & Rate
• Review planned course of day & answer questions
• Pre-Trial Ashworth Scale Scoring with Physician, Physical Therapist, Nurse, and family if present
• Appropriate dose of intrathecal baclofen for injection
• Lumbar Puncture
  • nurse assists with positioning
  • injecting intrathecal baclofen
• Monitoring for potential side effects:
  • respiratory depression, seizure,
  • headache, nausea, vomiting,
  • drowsiness, hypotension, weakness
• having physostigmine @ bedside
• anticipate discharge same day
  • (after medication wears off you might experience nausea& flu-like symptoms (from withdrawal) and will experience return of spasticity - discuss with physician about restarting oral anti-spastic pharmacotherapy taking prior to trial).
    
    

SCREENING PROTOCOL - Clinical assesment before and after test dose

• Assess spasticity in all affected muscle groups using Ashworth scale.
• Record spasm score.
• Grade all muscle stretch reflexes.
• Remember muscle strength and functional parameters (transfers, gait, etc.,) are not necessarily assessed during screening.

Pre ITB Trial Assessment - Physical Therapist

• Assess spasticity in all involved/uninvolved groups using the Ashworth Scale
• Assess for clonus
• Assess for ROM limitations - attempt to distinguish between soft/hard end feels
• Record spasm frequency
• Assess motor function
• Assess pain levels
• If the patient is dependent, interview the family members and/or caregivers to document difficulty, level and length of time to perform ADL’s
• The team discusses the pre-trial findings
  
  

SCREENING PROTOCOL - method of ITB administration

• Using syringe draw out 75ugs of baclofen from 500ug/ml 20ml vial (0.15ml) or use 50ug vial, keep sterile.
• Perform lumbar puncture.
• Introduce 75ugs (50ugs to 100ugs depending upon clinical situtation) baclofen completely via barbitage method.
• Place patient in a modified trendelenburg position after lumbar puncture for a determined period of time.
  

SCREENING PROTOCOL - baclofen bolus dose effects

• Onset of action in ~ 30 - 60 minutes.
• Peak spasmolytic effect in ~ 4 hours.
• Return to baseline in ~ 8 - 24 hours.
• Significant adverse effects very unusual with doses less than 100ugs.

SCREENING PROTOCOL - potential adverse effects of bolus ITB

Post ITB Injection Nursing Assessment

• Evaluate patient as per established protocol
• Ashworth Scale, Spasm Scale,BP, Pulse, Oxygenation
  @ 1/2hr, 1hr, 2hr, 4hr intervals after baclofen injection
• Patient lies flat first 2 hours
• Peak effect 2-4 hours
  

Physical Therapy Screening post administration of ITB

• Patient is assessed @ 30min, 60min, 2hrs, 4hrs, & 6hrs post administration of ITB via Ashworth Scale, Spasm Scale & Pain Scale
• Serial assessment - aware that peak spasmolytic effect of dose given is ~ 4hrs
• Transfers, balance, gait, bed mobility, gross motor function is generally assessed ~ 4hrs post ITB by team mutual consensus
  

Positive Responses to ITB

• A post trial fall in Ashworth Scale >or =2 for spinal and cerebral origin when compared to pre-trial score
• Reduction in frequency of spasms
• Decrease in pain
• Increased ROM
• Increased ADL function
  

ONGOING EDUCATION: Patient & Family regarding ITB

• Drug information: smaller doses; less side effects; does not involve permanent destruction of nerve pathways; adjustable; can be removed or turned off.
• Handouts: diagrams of pump & catheter; implant sites; frequently asked questions.
• Consults: orthopedic, neurosurgical, anesthesia, home care / social service --during trial to answer questions that may arise.

Patient -- Family Feedback

• Ongoing process --peaks with effectiveness of medication
• Patients / Caregivers goals for a positive trial
• Quality of life improvements
• Family members stopping by to see “improvements” - usually dramatic effect
• 95% of trials positive results (per patient & family expectations)
  

SCREENING PROTOCOL - positive response to ITB

• Dramatic subjective improvement in spasticity - judged by patient-family.
• Significant objective improvement as judged by fall in post -trial score on Ashworth spasticity scale by 2 or more points compared to pre-trial score, as well as a decrease in spasms.
• Adverse effects minimal and dose-related.

• "Try before you buy"

Does the patient respond to the trial bolus of ITB therapy?

• If the patient responds: proceed with implant -- if the patient desires.
• If the patient does not respond: do not proceed.