By Rocky Wilson
She says usage of implantable medicine pumps to
treat spasticity has doubled in the Spokane-Coeur d’Alene area in
the last four years, and the use of Botox injections for the same
reason has doubled in the past two years. The treatments don’t cure
severe spasticity, but can relieve its symptoms so that patients can
maneuver their own wheelchairs without assistance, feed themselves, or
even master enough muscle control to become active in the work force,
says Stanek, owner of Northwest Medical Rehabilitation PS. “Spasticity occurs in many different
disease processes,” Stanek says. “An inflammation in the
brain or spinal cord can create an imbalance of muscle
tightness,” such as muscle spasms for people suffering from a
spinal injury or who were born with cerebral palsy. “I work with patients with disabilities and help them become functional,” she says. Stanek is a certified physiatrist, which means
she’s a medical doctor who specializes in physical medicine and
rehabilitation. “I prescribe therapy, but I don’t do
therapy,” she says, adding that follow-up therapy is “a
very important piece” of any patient’s total rehabilitation
program. Stanek says she’s one of few physicians
here who prescribe the use of implantable baclofen pumps and injections
of Botox, known more widely as a cosmetic surgery drug, to combat the
condition. Baclofen pumps, implanted in a patient’s
abdomen, provide a steady flow of medicine through a catheter
that’s inserted into the intrathecal area, a spot underneath a
certain membrane around the spinal cord. Spasticity is characterized by tight, stiff
muscles that make movement, especially in the arms or legs, difficult
or uncontrollable. Patients diagnosed with spasticity most often have
suffered a serious injury to their spinal cord or brain, while others
have cerebral palsy, multiple sclerosis, or are victims of strokes. The pumps Stanek prescribes are implanted by surgeons and are known as intrathecal baclofen pumps. The injections of Botox, which is a protein complex, are done either instead of the surgery or in conjunction with it, she says. Northwest Medical Rehabilitation, which is
located at 1315 N. Division and employs 15 people, works with about 220
patients on an ongoing basis who have received a baclofen pump, Botox
injections, or both, Stanek says. She says the use of the implantable pump or
combination of the pump and Botox injections is done only in patients
with more severe degrees of spasticity, while Botox alone is used for
about half of the spasticity patients she sees. Baclofen pumps, which are round, about the size
of a tape measure, made of titanium, and battery operated, were first
implanted in patients to combat spasticity in 1988, though modern pumps
that could provide a more constant flow of medicine were first
commercialized in 2000. Botox, a purified protein complex derived from
bacteria, was used in cosmetic surgery before the U.S. Food and Drug
Administration approved it to help control certain types of spasticity
as well, in 2000, says Allergan Inc., its Irvine, Calif.-based
manufacturer. Stanek says it’s likely that many more
spasticity patients here would benefit from a baclofen pump or Botox
treatments if they knew they were available. “If more people were to use these tools to
treat spasticity, it would decrease the overall cost of treatment and
significantly improve their quality of life,” she says. Although most insurance companies cover both
treatments today, they are expensive, Stanek says. The cost of
implanting a baclofen pump, including the surgery, $10,000 price of the
device, and follow-up care, is about $26,000, she says. The Botox injections can cost as much as $4,200
for a three-month dosage, Stanek says. Patients receive up to four
injections in a single muscle, and up to 20 injections at a time if
they have spasms in multiple muscles, she says.
Spokane physiatrist Dr. Karen Stanek says a fast-growing number of
people here are using two little-known tools in the fight against a
debilitating muscle-contraction problem known as spasticity.
How they work
The surgery to implant a baclofen pump typically
takes one to two hours and requires a six-inch incision in the
patient’s abdomen, where the pump is implanted. Surgeons also
must make a two-inch incision in the patient’s lower back, where
a catheter is placed into the intrathecal space around the spinal cord
to administer the drug there. The other end of the catheter then is
maneuvered through the body so that it can be connected with the pump,
which supplies the drug to the fluid around the spinal cord.
Stanek doesn’t perform the surgical
procedure. She refers patients to one of only a handful of Inland
Northwest surgeons who do it. She says patients typically spend one
night in a hospital following the procedure.
The device pumps the liquid form of baclofen,
called Lioresal Intrathecal, through the catheter into the fluid
surrounding the spinal cord, where it blocks neurotransmitters from
triggering muscle contractions. Dispensed in this manner, the drug is
about 1,000 times less concentrated than the oral doses used years ago
to control spasticity, says Stanek. Those earlier, oral doses made
their way into the patient’s bloodstream, and there was no
guarantee that enough of the drug would end up where it was needed, she
says.
“This system works a lot better with a lot
fewer side effects,” such as drowsiness and nausea, she says. She
adds, “The pumps work a lot better in the lower extremities
because the heavy molecular weight of the baclofen has a tendency to
pull it down in the body.”
After the implantation procedure, pumps can be
adjusted telemetrically until the therapeutic dose of medicine to be
released continuously into that patient’s spinal fluid is
determined, she says. That amount varies with each patient. Every 60 to
90 days, a needle filled with the drug is inserted through the
patient’s skin into a special port in the baclofen pump to refill
the pump’s reservoir, says Stanek.
Baclofen pumps typically are replaced every five to seven years, when their batteries run out, she says.
Patients with baclofen pumps are warned about
the importance of keeping all refill appointments because any abrupt
stoppage of Lioresal Intrathecal can result in serious medical
problems, says Allergan.
Stanek says about 40 percent of patients treated
at Northwest Medical Rehabilitation receive both baclofen pumps and
injections of Botox.
Stanek commonly injects Botox directly into
muscles that are susceptible to spasms or tensing up, and it usually
stays confined to those muscles, she says.
Allergan’s promotional material says
Botox’s impact on spasticity revolves around the protein
complex’s ability to influence the substance acetylcholine, which
typically transmits messages from nerves to muscles that make muscles
contract and move.
Too much acetylcholine causes spasticity
problems, whether they’re spasms or tensed-up muscles, the
pharmaceutical company says. Botox blocks nerves from releasing
acetylcholine, thus relieving at least some symptoms of spasticity, it
says.
Three months ago, Stanek launched the Northwest
Medical Rehabilitation Foundation to raise funds to finance baclofen
pump implantations and Botox injections for patients whose treatments
aren’t covered by insurance.
Contact Rocky Wilson at (509) 344-1264 or via e-mail at rockyw@spokanejournal.com.
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