Spasticity Management
The information on this page was obtained from notes from Dr. Kimberly BeDell's presentation at the Octorber, 2000 NORD conference. Dr. BeDell is a Pediatric Physiatrist on staff at Miller Children's in Long Beach, CA. This page is for informational purposes only. Please consult with your physician before making decisions on any of these treatments.
Pediatric Rehabilitation is made up of:
A team approach
Short and long term goals
Education of the patient and family
Spasticity is a disorder of the muscle tone with central nervous system involvement.
Spasticity affects all aspects of life and leads to other conditions such as contractures and thrombosis in adults.
It is possible that you do not want to get rid of all spasticity. If muscles are weak then you would want to keep some spasticity for functional purposes.
Evaluation consists of the following:
Gait
Range of Motion (ROM)
Resting
Balance skills
Orthoses
Sleeping patterns
Endurance—spasticity can wear you out but so can medications used to control spasticity so have to be careful.
Fine motor skills
Bed mobility
Wheelchair management
Tests used for evaluations:
Modified Ashworth Scale
Global Pain Scale (do you have pain?)
Spasm Frequency Score
Bilateral Adductor Tone
How does the spasticity affect activities of daily living (ADLs)?
Gait pattern
Transfer abilities, etc.
Goals of spasticity management:
Decrease pain
Decrease contractures
Improve mobility
Facilitate activities of daily living
Increase safety
Save caregivers time—example would be decreasing tone in adductors would make changing diapers much easier and would take less time.
Management techniques:
Modalities: heat, cold, electrical stimulation, ultrasound
Fabrication: splinting, bracing, serial casting, adaptive seating
Removing noxious stimuli—spasticity is worse with any added negative condition such as constipation, UTI, etc.
Surgery:
SDR—(selective dorsal rhizotomy)—brain and spinal cord are sending too many messages to move muscles. This procedure stops the message from the spinal cord to the muscle by cutting certain nerve rootlets.
Cordotomy—this consists of severing the nerve fibers on one or both sides of the spinal cord that travel the express routes to the brain. This is very drastic and seldom done.
Neurectomy—removal of a nerve or a portion of a nerve, also considered drastic and seldom done.
Tendon release or transfer—this is the most common procedure. It is best to prolong this procedure as long as possible with the above management techniques and/or with use of medications. The longer you delay and allow for growth, as long as no contractures or deformities are occurring, the less often you will have to repeat the procedure.
Medications used to reduce spasticity:
Valium--this is not for chronic control. It works well for Baclofen withdrawal. Can cause fatigue.
Baclofen—can be given orally (in milligrams) or intrathecally (in micrograms). Oral is the most common first try medication. Intrathecal does not have as many side effects. Baclofen can decrease the seizure threshold. Can cause fatigue.
Baclofen pumps can last 7 years. They need to be refilled with medication every 3 months. Are said to be mainly for help with spasticity in lower limbs but if catheter is placed further up in the intrathecal space in the spinal column then it can help spasticity in the upper body as well. Some places are getting away from trial periods before baclofen pump placement. Those that do use trial periods it usually consists of a one day hospital observation. For dystonias however it is a 4 day trial period with catheter placement. A physical therapist comes in 4x/day during the trial to make sure it is working. Pumps can be placed in younger children if there is sufficient abodomen space.
Zanaflex—not FDA approved for children under 12 but is given to them because of its effectiveness. Side effects include fatigue and liver enzyme problems. Liver enzymes need to be checked at 1, 3 and six months after beginning medication. If all looks good then enzymes need to be checked yearly after that. Can cause fatigue.
Dantrolene—works at muscular level. Do not use in patients with cardiac or respiratory problems. Can cause fatigue.
Catapres—this is a blood pressure medication and is used in conjunction with other spasticity medications. Can cause fatigue.
Botox—injections. Great for focal spasticity. Onset of effect is 2-14 days. Lasts anywhere from 6 weeks to 6 months. 10% of patients fail to respond. Injections are expensive. Can repeat no earlier than 3 months. Physical and occupational therapy can be done right away. Hard to get exact desired effect which can cause not enough reduction in spasticity or too much of a reduction.
Phenol—injections, can destroy tissue around the injection site. Phenol blocks are inexpensive but time consuming. They are painful and require sedation of the patient. Can cause dysthesias or a pins and needles felling if injected in a site that has lots of sensory nerves. Adductors are a good area to do this procedure because there are not many sensory nerves located there. The effects of these blocks are seen immediately so it makes it easier to get the exact desired effect where with botox it takes several days to get the maximum effect. Lasts longer than botox but has to be repeated.
Neurotin—seizure medication that can be added to another med to help. Also can cause a problem with fatigue.
Botox In Spasticity Management
Focus on Pediatric Spasticity Management
Intrathecal Baclofen Therapy
The Road To Recovery
Spasticity Evaluation & Management
Spasticity Managment for People with Cerebral Palsy
Treating Spasticity - Oral Medications and Surgery
Treatment of Spasticity
