Topic Krug Spas Ti City

Patient Management

Program Objectives • Define spasticity, related anatomy, and current understanding of the pathophysiology of spasticity and other movement disorders. • Describe the benefits and detriments of spasticity and how they relate to goal setting. • Describe patient examination and evaluation, including the use of appropriate outcome measures, and related rehab interventions. • List the indications, risks, and benefits of current treatment options. • Discuss the role of the interdisciplinary team in the assessment and treatment of spasticity.

Spasticity (Lance, 1980) • • • • • •

Motor disorder Velocity dependent increase in tonic stretch reflexes Hyperexcitability of the stretch reflex Exaggerated tendon jerks One component of the upper motor neuron syndrome Altered activity patterns of motor units occurring in response to sensory and central command signals which lead to co-contractions, mass movements, and abnormal postural control (Wiesendanger, 1991)

Upper Motor Neuron Syndrome (UMNS) Positive Signs • Spasticity • Rigidity • Hyperreflexia • Primitive reflexes • Clonus

Negative Signs • Lack of strength • Lack of motor control • Lack of coordination

(Young, 1989; Young, 1997)

Pathophysiology of Spasticity Proposed Theories: 1. Imbalance between excitatory and inhibitory impulses to the alpha motor neuron --Due to lack of descending inhibitory input to the alpha motor neuron

Pathophysiology of Spasticity 2. Descending pathways also influence Renshaw cells (neurons located in ventral horn) which suppress repeated firing of alpha motor neurons --lesion decreases activity of Renshaw cells = reduce their inhibitory activity --this results in rapid, repeated firing of alpha motor neurons from repetitive stretch reflexes triggered by voluntary or passive stretch of muscle.

Pathophysiology of Spasticity 3. Descending pathways also inhibit Golgi Tendon Organ (GTO) --lesion results in lack of inhibition of GTO = excitation of stretch reflex

Range of Muscle Tone

Flaccidit y

Hypoton ia

Normal Range of Muscle Tone

Hyperto nia

Rigidity

Involuntary Movement Disorders Dystonia:

Abnormal posturing, twisting, or repetitive movements

Chorea:

Irregular dance-like movements

Athetosis:

Writhing, distal movements

Choreoathetosis: Combination of both chorea and athetosis Ataxia:

Flailing movements, wide-based gait

Contracture The difference between the joint angle at which extreme resistance to passive movement occurs and normal end-range of motion.

(Olney & Wright, 1994)

Contracture • Spasticity involves increased muscle activity from the agonist muscle group that is not balanced by its antagonist • Results in persistent, abnormal joint positions • Other factors that influence joint mobility – – – – –

Musculoskeletal growth in CP Arthritis (osteo and rheumatoid) Previous injuries to joints or soft tissue Previous orthopedic surgeries Heterotopic ossification

Possible Advantages of Spasticity • Maintains muscle bulk • Helps support circulatory function –

May prevent formation of deep vein thrombosis

• May assist in activities of daily living • May assist with postural control

Consequences of Spasticity • May interfere with mobility, exercise, joint range of motion • May interfere with activities of daily living • May cause pain and sleep disturbances • Can make patient care more difficult

Considerations • Spasticity waxes and wanes • Dynamic vs static tone • Multiple muscle groups may contribute to joint deformity • Patient perception

Clinical Challenge "Spasticity is more difficult to characterize than to recognize and STILL MORE difficult to quantify".

(Katz & Rymer, 1989)

The Therapist Role in Spasticity Management • Identify, evaluate, and educate the patient • Guide the patient in setting goals • Provide rehabilitation interventions that: – – –

Decrease the influence of the positive signs Improve the negative signs Facilitate newer rehabilitation techniques

• Provide feedback and consultation to rest of spasticitymanagement team

Treatment Options for Patients with Spasticity Intrathecal Baclofen (ITB™) Therapy Oral Medications

Rehabilitation Therapy

Patient Orthopedic Surgery

Injection Therapy Neurosurgery

Oral Medications Most common: • Baclofen (Lioresal®) • Diazepam (Valium®) • Tizanidine (Zanaflex®) • Dantrolene sodium (Dantrium®)

Site of Action for Oral Medications Drug

Site of action

Baclofen

Central Nervous System

Diazepam

Central Nervous System

Tizanidine Dantrolene sodium

Central Nervous System Peripheral: muscle

Oral Medications: Considerations Decrease positive signs • Spasticity, Dystonia (multi-segmental) • Spasms

Improve negative signs • Lack of Motor Control (use rehab to address)

Consider other negative signs • Lack of Strength (consider whether decreasing hypertonia would be detrimental to posture and function)

Oral Medications Advantages • Non-invasive, not permanent • Effective management for some patients

Disadvantages • Difficult to achieve a steady state • Following a schedule may be difficult • Side effects: drowsiness, hypotonia, and weakness may limit effectiveness

Injection Therapy • Anesthetic / Diagnostic Nerve Blocks – –

Procaine Lidocaine

• Neurolytic Nerve Blocks – –

Ethanol Phenol

• Botulinum Toxin

Botulinum Toxin • Clostridium botulinum injected into the muscle • Interferes with release of acetylcholine at the neuromuscular junction • No systemic effect • May be administered without anesthesia • EMG guidance for small muscles • Results typically last 3-6 months

NMJ

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114

NMJ Proteins

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114

Botox Effect on NMJ

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114

Injection Therapy: Considerations Decrease positive signs • Focal spasticity or dystonia • Contracture

Improve negative signs • Lack of Motor Control (use rehab to address) • Lack of Strength (use rehab to address) –

opportunity to work on strength and better alignment

Consider other negative signs • Lack of Strength (consider whether decreasing hypertonia would be detrimental to posture and function)

Injections Advantages • Not permanent • Evidence to support efficacy in reducing spasticity and improving function • Effects are localized - not systemic

Disadvantages • Not permanent - may need to repeat injections • Ethanol and Phenol: require greater skill to inject, increased risk of paresthesias, dysesthesias • Botulinum toxin: more expensive than other injections, may develop antibodies

Why Botox Wears Off • Sprouting

Courtesy of Medtronic ITB™

Intrathecal Baclofen (ITB™) Therapy

Courtesy of Medtronic ITB™

Intrathecal Delivery of Baclofen • Acts as GABAb – receptor agonist – –

GABA (gamma-amino butyric acid) is an inhibitory CNS neurotransmitter Two receptor types (GABAa and GABAb)

• Mechanism of action is probably presynaptic inhibition – –

Inhibits release of calcium into presynaptic terminals Thereby impedes release of excitatory neurotransmitters

• Baclofen is delivered directly into CSF in intrathecal space

Why Intrathecal vs. Oral? • Intrathecal – –

Lower doses than those required with oral administration Potentially fewer systemic side effects

• Oral –

– –

Low blood/brain barrier penetration, with high systemic absorption and low CNS absorption Lack of preferential spinal cord distribution Adverse effects, such as drowsiness, for some patients

Pharmacokinetics of Baclofen • Intrathecal – – –

600 mcg/day dose: 1.24 mcg/mL IT lumbar concentration Lumbar to cervical concentration is 4:1 with lumbar catheter tip placement Therapeutic dose is 1/100 of oral

• Oral – –

60 mg dose: 0.024 mcg/mL IT lumbar concentration Half-life 3-4 hours

(Knutsson et al, 1974; Kroin & Penn, 1991)

SynchroMed® Infusion System Components Pump • infuses drug at

programmed

rate

Catheter • delivers drug to the intrathecal (subarachnoid) space of the spinal cord

Programmer • allows for precise dosing • easily adjustable dosing

Courtesy of Medtronic: SynchroMed ® EL Infusion System

Indications for ITB™ Therapy • Patients must demonstrate a positive response to the screening test • Patients with spasticity of spinal origin: – –

unresponsive to oral antispasmodics and/or experience unacceptable side effects at effective doses of oral baclofen

• Patients with spasticity of cerebral origin must be one year post brain injury to be considered for ITB Therapy

ITB™ Therapy Process Stage 1: Patient Selection Stage 2: Screening Test Stage 3: Implant Stage 4: Maintenance, Follow-up, & Rehab

Screening Test Flow Chart Bolus: 50 mcg

+

24 hrs after Bolus: 75 mcg

+ +

= Positive Response “Implant”

-

= Negative Response “No Implant”

24 hrs after Bolus: 100 mcg

+

Intrathecal Baclofen Therapy Clinical Reference Guide for Spasticity Management, Medtronic, Inc.

Not a Candidate

Therapy Examination During the Screening Test • Typically assess at 2 and 4 hours post bolus • Ashworth or Modified Ashworth Scales (AS or MAS) • Passive/Active Range of Motion (PROM / AROM) • Observe movement patterns • Spasm Scale • Pain Scale

Therapist Role PostImplant • Determine appropriate therapy venue • Propose treatment plan • Provide input regarding dosing

Potential Risks of ITB™ Therapy • Common side effects: – – – – – –

Hypotonia Somnolence Nausea/vomiting Headache Dizziness Paresthesias

• Catheter and procedural complications may occur • Overdose (rare) • Withdrawal

Baclofen Overdose • Symptoms – – – – – – – –

Drowsiness Lightheadedness Dizziness Somnolence Respiratory depression Seizures Rostral progression of hypotonia Loss of consciousness (possible progression to coma)

• Take patient to emergency department!

Baclofen Withdrawal • Symptoms – – – – – – – – – –

Increased spasticity Itching without rash Tingling, paresthesias, skin "crawling" Hyperthermia Headache Hypotension Seizures Hallucinations Altered mental status Autonomic dysreflexia = medical emergency

ITB™ Therapy: Considerations • Decrease positive signs during screening test –

Spasticity

•Improve negative signs –Lack

of Motor Control (use rehab to address)

•Consider other negative signs –Lack

of Strength (consider whether decreasing hypertonia would be detrimental to

ITB™ Therapy: Considerations • Positive signs - ITB Therapy will not change these signs – –

Intrinsic muscle properties Contracture

• Negative signs - will need rehab to see changes – –

Lack of Strength Lack of Balance

Efficacy of ITB™ Therapy in Adults and Children • Positive responses to screening trials: – –

86% cerebral origin 97% spinal cord origin

• Upper and lower extremity effects noted • Improvements for patients with functional goals & for patients with goals of improving comfort and ease of care

(Albright et al, 1991; Albright et al, 1995; Penn et al, 1989; Medtronic data on file)

ITB™ Therapy • Advantages – – – – –

Reversible Non-invasive dose adjustments Potential for fewer side effects than oral drugs Evidence to support efficacy in reducing spasticity May improve function, comfort and care

• Disadvantages – – –

Complications: infection, catheter problems, overdose, baclofen withdrawal Refills – approximately every 3 months Cost

Neurosurgical Treatments • Neurectomy • Myelotomy • Anterior Rhizotomy • Selective Dorsal Rhizotomy • Cordectomy • Thalamotomy (Simpson, 1995)

Selective Dorsal Rhizotomy (SDR) Dorsal sensory nerve roots are severed Each rootlet within root is stimulated Abnormally-responding rootlets are severed Often performed on children between ages of 7 and 10 years • Usually involves 6-12 months of intensive therapy post-operatively if improved function is goal • Complications include possible sensory loss • • • •

(Abbott et al, 1993; Van de Wiele et al,

Selective Dorsal Rhizotomy (SDR)

Antonio R. Prats, M.D., F.A.C.S., Miami, Florida

SDR: Considerations • Decrease positive signs –

Spasticity (multi-segmental)

• Improve negative signs –

Lack of Motor Control (use rehab to address)

• Consider other negative signs –

Lack of Strength (consider whether decreasing hypertonia will be detrimental to posture and function)

(McLaughlin et al, 1998; Steinbok et al, 1997;

SDR • Advantages – –

Permanent – one-time procedure Evidence for efficacy in reducing spasticity and improving function in children with spastic diplegia

• Disadvantages – – –

Permanent – may need spasticity Potential adverse effects: spinal, sensory Not effective for dystonia

Orthopedic Surgery • Soft-tissue operations – – –

lengthenings releases tendon transfers

• Bony operations – –

osteotomies fusions

Orthopedic Surgery: Considerations • Decrease positive signs – –

Contracture Abnormal Bony Alignment

• Improve negative signs – –

–

Lack of Motor Control (may improve with rehab) Lack of Strength (may improve with better biomechanical alignment, may require rehab) Lack of Balance (may improve if better base of support)

Orthopedic Surgery • Advantages –

Effects usually last a few years

• Disadvantages – – –

Anesthesia risks Non-weightbearing after bony procedures Risk of weakness, decreased function

Interdisciplinary Approach Treatment Team Members Family and Caregiver Nurse Social Worker Speech Therapist

Physiatrist Neurologist

Person with Spasticity

Orthotist Seating Specialist

Primary Care and Family Physician

Physical and Occupational Therapists Neurosurgeon Orthopedist

Rehabilitation • Advantages – – –

Noninvasive Active involvement of the patient and/or family Emphasis on functional gains

• Disadvantages – – –

Casting, orthoses, positioning: skin integrity at risk Cost of treatments, equipment Requires patient motivation & participation for functional gains, motor learning

Elements of Patient Management for Optimal Outcomes Guide to Physical Therapist Practice

Elements of Patient Management Diagnosis Evaluation

Prognosis Outcomes

Examinati on

Interventio n

Patient Examination • Patient history • Psychsocial factors • Tests and measures

Patient History • Focal or generalized tone • Evolution of spasticity • History of intervention • Past medical history • Comorbidities • Chief complaint • Patient’s/caregiver level of understanding

Psychosocial Factors • Coping strategies/parenting styles • Learning styles • Cognition • Family/community support • Funding sources

Tests and Measures Muscle Performance Range of Motion Integumentary Integrity Pain Orthotic, Protective, and Supportive Devices Fatigue/Cardiovascular Endurance Posture Reflex Integrity Neuromotor Development and Sensory Integration • Self-care and Home Management • • • • • • • • •

Tests and Measures for Muscle Performance • Static and dynamic muscle tone • Muscle strength and selective motor control • Function

Static Muscle Tone • Ashworth and Modified Ashworth scale • Tardieu scale • Spasm Frequency scale • EMG/ H Reflex

Modified Ashworth Scale Scor Criteria e 0

No increase in tone

1

Slight increase in tone (catch and release at end of ROM)

1+ Slight increase in tone, manifested by a catch, followed by minimal resistance throughout remainder (less than half of the ROM) 2

Marked increase in tone through most of ROM, but affected part(s) easily moved

3

Considerable increase in tone; passive movement difficult

(Bohannon & Smith,

Modified Tardieu Scale: (Boyd, 1999) • Consistent velocity stretch of muscle • Standard positions for specific muscles • Note point of resistance to maximal velocity stretch (R1) • Note amount of muscle contracture or muscle length (R2) • Relationship between R2-R1

Spasm Scale Spasm Frequency Score Criteria 0 No spasms 1 No spontaneous spasms (except vigorous stimulation) 2 Occasional spontaneous spasms easily induced 3 >1 but <10 spontaneous spasms/hr 4

>10 spontaneous spasms/hr

Penn, Savoy, New England Journal of Medicine, 1989, 320:1517-1521.

Dynamic Muscle Tone • Observation of Movement Patterns – – – –

Equinus gait Scissor gait Upper extremity flexion/adduction Mass movement postures

• Observation Tips – –

Try observing with and without orthoses or ambulation aids Video taping can be very helpful

Additional Examination Considerations • Assistive devices utilized • Seating system • Positioning • Functional tasks • Status of oral medications

Typical Upper Extremity • Shoulder: internal rotation • Elbow: flexion • Forearm: pronation • Wrist/ Fingers: flexion • Thumb: in palm

Typical Lower Extremity Postures • Hip & Knee Extended • Ankle Plantarflexed • Foot/ ankle inverted OR

• Hip & Knee flexed • Ankle Plantarflexed

Consider the Positive Signs • Is there: – – –

Moderate to severe spasticity? Static or dynamic spasticity? Generalized or focal spasticity?

• What are the effects on: – – – –

Function? Comfort? Care? Safety?

• Is intervention directed at these signs warranted?

Possible Advantages of Spasticity • Maintains muscle bulk and tone • Helps support circulatory function • May assist in transfers and ambulation • May assist in activities of daily living

Consider the Negative Signs • Is there a lack of: – – – – –

Strength? Motor control? Coordination? Balance and posture? Endurance?

• What are the effects on: – – – –

Function? Comfort? Care? Safety?

• Is intervention directed at these signs warranted?

Consequences of Spasticity • May interfere with: ADLs: dressing and hygiene  Mobility: rolling, sit ⇔ supine, transfers, ambulation  Exercise  Joint range of motion  Coordination of movement  Ability to move: ↑ effort  Tolerance of orthotics/ splints  Skin integrity  Ability to sleep/ rest  Feeding and speech  Patient Care  Driving 

Clinical Evaluation and Patient’s Perspective Most importantly, Does spasticity interfere with function, care, or comfort?

Is Spasticity a Problem? Goals of Spasticity Management • Decrease spasticity • Improve functional ability and independence • Decrease pain associated with spasticity • Prevent/ limit contractures • Improve mobility/ ambulation • Facilitate ADLs/ hygiene • Save caregiver time & effort

Gait Assessment • Foot clearance with swing • Foot position at late swing • Step length • Leg position in stance • Amount of effort required to ambulate

Abnormal Gait in Spastic Diplegia • • • • • • •

Gait is delayed and requires great effort Adducted with IR of Hip Increased knee flexion Forefoot strike Early heel rise Excessive lumbar lordosis Circumducts or excessively flexes hipknee to advance leg

Abnormal Gait with Spastic Hemiplegia • Toe strike • Knee hyperextension • Posturing of ipsilateral upper extremity • Trunk lean

Abnormal Gait with Spastic Hemiplegia • To advance LE: – – – – –

Hip hiking Trunk lean to opposite side Circumduction Excessive Hip & Knee Flexion Vaulting

Abnormal Gait with Spastic Hemiplegia

Functional Prognosis: Primarily Ambulatory • Balance and safety • Endurance and energy conservation • Gait pattern • Additional areas where skill level could improve – –

Driving Athletic performance

Functional Prognosis: Primarily Wheelchair Use • Transfers, mobility, and safety • Position and function in wheelchair • Additional goals could include: – – – –

Fine motor control: switch access Speech Feeding: oral motor skills Preparation for other interventions

Rehabilitation Therapy • • • • •

Stretching Casting Orthoses Weight bearing Positioning & Seating: -Podus Boots -Versaform -Splints/ Bivalves -Aircast • Practice functional tasks • Sensory Integration

• EMG biofeedback • Electrical stimulation • Vibration of the antagonist • Constraint-induced Movement Therapy • Selective Strengthening of Antagonist • Aquatic Therapy • Handling/ Inhibitory Pressure

Focus on…. • • • •

Elongation of shortened tissues Strengthening Improving motor control Address underlying weakness

Treatment Approaches • NDT: – – –

Normalize muscle tone/ posture Inhibit reflexes Facilitate normal movement  Use of handling/ facilitation techniques

• Motor Learning –

Practice functional tasks

Treatment Approaches • Therapeutic Exercise: – – – – – – – – – – –

Stretching and ROM Active assistive, active, & resistive exercise E-stim. (fatigue OR strengthen) Weight bearing Aquatic therapy Rhythmic rotation Contract-Relax Handling/ key points of control Inhibitory pressure Ice Warmth Biofeedback

Treatment Approaches • Functional Training: – –

gait, ADLs, mobility, school-based (to enhance education) Consider equipment and environmental adaptations to maximize function

Other Treatment Approaches • • • •

Restraint-induced Play FES School based vs. medically based

• ***Not just one approach…blending of what’s effective for patient

Positioning • Positioning: (in bed, w/c, and other) – – – –

Podus boots Versaform Splints Aircast

Positioning

Casting/ Splinting • Inhibitory Casting • Serial Casting • Bivalve Splints • AFOs • SMOs • Upper Extremity/ Hand Splints

Inhibitory Casting • Theoretical Principles: – – –

–

Static positioning interrupts stretch reflex Circumferential casting provides neutral warmth and constant pressure Decreases variability of cutaneous sensory input which can elicit stretch reflex Promotes changes in muscle tendon length and sarcomere distribution

Inhibitory Casting • Indications: – – – –

Elevated muscle tone present Full/ functional ROM present Little isolated, active (non-synergistic) movement is present “Holding” or “posturing” is observed

Inhibitory Casting • General Principles: – – – – –

Cast in sub-maximal range Leave on 3-5 days Complete a thorough assessment after removal Apply new cast or bivalve ASAP Use with abnormal movement

Serial Casting • Theoretical Principles: –

– –

Low-force, long-duration stretch produces residual elongation of connective tissue Gentle, prolonged stretch results in cell division Provides inhibitory effect

Serial Casting • Indications: – –

Spasticity is present Loss of PROM is significant

Serial Casting • General Principles: – – – – –

Apply cast in submaximal range Leave on 5-10 days Complete thorough assessment after removal Casting multiple joints Decide what to do next (cast or splint):  If cast again , do immediately  If splinting, do ASAP

Therapist Evaluation Prior to Casting • • • • • •

Cognitive status Sensation Skin integrity Effects of positioning and gravity Psychosocial issues Recommendation for other interventions (botox) • Type of casting: serial vs. inhibitory • Quality of motion: – –

Active vs. passive Isolated vs. synergistic

– Do

ALL prior to casting and again AFTER each cast

Contraindications for Casting • • • • • • •

Medically unstable Edematous areas Fragile skin Compromised circulation Agitation and confusion Impaired Sensation Open Wounds: – –

Abrasions Lacerations

Contraindications for Casting • Multiple Extremities • Multiple Joints • Bony Malformations: – – – – –

Subluxation Unhealed fracture HO Loose bodies Arthritis

Cast Padding

Caregiver Monitors: • • • • • • • •

Pulse and respirations Skin temp Skin color Pain Edema Reddened areas or blisters Cast condition Limb position

General Info on Casting • Casting is usually most effective proximal  distal; will see some distal inhibition with proximal inhibition • Need to prioritize individually per patient needs, medical status, and tolerance • Heat generated in a cast may be in itself inhibitory for tone

More General Info on Casting & Spasticity Management • Air splints are generally ineffective as means of inhibiting tone due to softness and inconsistent pressure; best used for positioning during treatment • Whole body positioning may be beneficial; primitive reflex patterns and synergies need to be inhibited to decrease tone • Serial casting uses same principles of Inhibitory, but low load, prolonged stretch = physiologic changes (↑ in sarcomeres) = permanent change in muscle length

Long Arm Cast

Drop-out Elbow Cast

Gillen G & Burkhardt, A, Stroke Rehabilitation: A Function-Based Approach. Mosby: St. Louis, 1998

Drop-out Cast

Hand & Wrist Casts

Hand & Wrist Casts

Gillen G & Burkhardt A, Stroke Rehabilitation: A Function-Based Approach. Mosby: St. Louis, 1998

Leg Casts

Casting Another tool in our bag -cost-effective vs medical -fairly non-invasive -it works!

Therapists • Input for selection of muscle injection/ surgical intervention/ medication based on functional picture • Feedback to physician regarding effects of medical management • Suggestions/ ideas for future management to maximize function • Seek input of other team members • Monitor patient for changes in status • Provide inhibition & facilitation techniques; especially after casting &/or medical treatments • Serve as referral source in community • Assist with oral motor skills

Reassess Equipment Needs • Seating system • Standing equipment • Orthotics • Bathroom equipment • Assisted technology • Augmentative communication

Adult Outcomes: General • Functional Independence Measure (FIM) • Functional Assessment Measure (FAM) • Canadian Occupational Performance Measure (COPM) • Goal Attainment Scaling (GAS) • Timed Up and Go (TUG) • Pain Scales

Adult Outcomes: General • Barthel Index • Observational Gait Scale (OGS) • Sickness Impact Profile (SIP) • SF-36 (QOL measure) • 3-Dimensional Gait Analysis (3DGA)

Adult Outcomes: Stroke • Chedoke-McMaster Stroke Assessment (CMSA) • Berg Balance Scale (BBS) • Tinetti Balance Scale

Adult Outcomes: MS • Multiple Sclerosis Functional Composite (MSFC) • Minimal Record of Disability for MS (MRDMS) • Modified Fatigue Impact Scale (MFIS)

Evidence: Botox • Effective and safe to manage spasticity in children: – – – – – – –

Love et al Desloovere et al Boyd and Hays Chambers Fragala Graham Houltram et al

Evidence: Botox • and Adults: – – – – –

Hesse et al Pierson et al Yablon et al Simpson et al Graham and Rawicki

Evidence: Casting • Effective in improving ROM and reducing spasticity – – – – – – –

Hill Barnard et al Nash Mortenson and Eng Cottalorda et al Lehmkuhl et al Booth et al

Evidence: Botox vs. Casting • Houltram et al • Flett et al • Corry et al – – –

Significant improvement in tone reduction and gait for both groups Botox was preferred treatment by caregivers Botox lasted longer

Evidence: Botox & Casting • Booth et al: both together caused faster results (improved gait and ROM) as compared to just casting • Desloovere et al: Group casted AFTER Botox improved more with 3DGA than group casted PRIOR to Botox • Graham et al: Less regression and loss of function if casted with Botox than if surgery

Cases

Jeffrey • 6 y/o; CVA at birth/ CP: Left Hemi • OT/PT since 1y/o, 1-2X/ week • Spasticity Left upper & lower extremities • Impaired Left sensation/ position sense • Gait: toe walker, decreased step length on right, circumduction to advance left leg • Impaired balance: especially in standing • Short hamstrings: poor sitting posture

• Treatment: – – – –

Botox: left finger and wrist flexors; left plantarflexors & hamstrings Inhibitory Casting left foot/ ankle in DF Inhibitory Casting left hand/ wrist in neutral Weight bearing:   

– – –

–

Jeffrey

Hands and knees Side-sitting stance

Dynamic stretch to hamstrings and gastrocs Splints worn at nighttime Home Program: long sitting while playing games, use of left hand, stretching, wrist extension and ankle DF Coordination & balance activities

Jeffrey’s Outcome • Began walking with occasional heel strike/ flat foot • Improvements with balance during gait & on stairs • Began jumping (still uses R > L) • Able to move ½ kneel ⇒ stand over left leg • Hops on left leg with help ∀ ⇓ Limp (still present) ∀ ⇑ speed/ started running

Jeffrey’s Outcome • Ongoing: – –

– – –

lack of heel strike decreased push-off on left ⇓ stability in Quad uses R > L Mild “limp” Difficulty with advanced motor/ coordination activities

Jeffrey’s Outcome • Opens hand & fingers • Controlled grasp & release • Can obtain neutral forearm position ∀ ⇑ strength proximally • Function: uses left as assist 

Ex: shoe tying

• Began walking with occasional heel strike/ flat foot • Improvements with balance during gait & on stairs • Began jumping (still uses R > L) • Able to move ½ kneel ⇒ stand over left leg • Hops on left leg with help ∀ ⇓ Limp (still present) ∀ ⇑ speed/ started running

Jeffrey’s Outcome • Ongoing: – – – – –

– – –

Grip strength= poor Lacks full supination Trunk substitution for IR and ER lack of heel strike decreased push-off on left ⇓ stability in Quad uses R > L Mild “limp” Difficulty with advanced motor/ coordination activities

Sarah • 21y/o, TBI due to MVA • Rancho II • Significant Spasticity throughout extremities, trunk, neck • Video:

Conclusion Choose the treatment or treatments that address the positive and negative signs interfering with attainment of the patient and family/caregiver goals, keeping in mind the psychosocial and medical factors. COMMUNICATION: With

other team members With Physician

Credits • To Edward Wright, MD and LeaAnn Brittain, ME, OTR who originally developed parts of this presentation • To Giulianne Krug, ME, OTR for providing information on spasticity and benefits of casting. • To Medtronics for data and information, graphics and formatting used within this presentation.

References and Suggested Reading 10- page list of references can be viewed separately