spasticity management

[ED50]

I have a patient that is on 80mg baclofen due to c spine injury - with resultant myelomalacia. Still having significant upper and lower extremity spasticity (baclofen helps). What would be your next step? Increase baclofen, add another agent, consider Botox, consider something else? Curious where you all would go from here.

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[runfastnow]

If certain muscle groups really cause issues with ADLs then would Botox/Xeomin/etc. those muscle groups. Otherwise I would look at a baclofen pump.

 

[PMR2008]

Pump trial would be the best next step.

 

[RangerBob]

You can certainly consider a pump, though that won’t help much with UE spasticity.

We had a huge pump/spasticity program where I trained. My attending was number 1-3 in the US (varied each year) for the most amount of Botox used (spasticity is just what he did for a living). Typically we’d do pump trials when patients were maxed out on multiple PO meds (typically 3 agents) or they couldn’t tolerate them.

I wouldn’t call 80mg of baclofen maxed out yet. It’s the normal max dose, but for SCI you can go higher—up to 120mg with benefit. We did it regularly.

I’d personally start with increasing baclofen or adding tizanidine (check LFTs) prior to something as invasive as a pump. And consider Botox for the most problematic areas.

 

[DMBandFan86]

I usually stop around 80 mg baclofen a day. You can try higher, but I would only continue if they get significant benefit from the increase. But I agree, why not try a second medication first? tizanidine, clonidine, dantrolene, valium, cyproheptadine, medical marijuana.

Pumps can be life changing when they work well. They can also be a disaster in a small group of people.

 

[j4pac]

Pump + Botox probably better but patient selection is key. If 20 mg Baclofen isn’t working, the gain of flooding gabaB more is pretty small. Pretty sure that there’s a ceiling effect. I’d try another to see if hitting another receptor would be more beneficial...just be mindful of oversedation