CP - Spasticity Management

Question 1

How is spasticity managed in CP?

Answer 1

• Botulinum Neurotoxin Type A (BNTxA) Injections
• Oral medications and ITB
• Selective Dorsal Rhizotomy

Question 2

What are the treatment categories for hypertonicity?

Answer 2

• Generalised/focal

- Reversible/permanent

Question 3

What are the generalised treatments for hypertonicity?

Answer 3

• Reversible: Oral meds, ITB

- Permanent: Dorsal Rhizotomy

Question 4

What are the focal treatments for hypertonicity?

Answer 4

• Reversible: Splints, casts, therapy, botox

- Permanent: Orthopaedic surgery, phenol blocks

Question 5

What does botox cause?

Answer 5

• Reversible blockade of ACh release at NMJ
• Neuro toxin is internalised into nerve endings by endocytosis
• Recovery takes place over several weeks - 3 months

Question 6

What are the goals of botox treatment for children rated GMFCS 1-3?

Answer 6

• Gait related

- Improve sitting balance & function

Question 7

What are the goals of botox treatment for children rated GMFCS 4-5?

Answer 7

• Facilitate hygiene care

- Sitting posture

Question 8

What are some of the other goals of botox treatment?

Answer 8

• Facilitate orthotic management
• Continue conservative management until gait is
  mature
• Evaluating short term functional gain to provide
  info for future treatment plan
• Simulate surgery result
• Facilitate training to achieve better condition prior to
  surgery
• Treatment of pain caused by spasms (spastic-
  athetoid), or due to hyperlordosis

Question 9

How does botox work?

Answer 9

• Injected into NMJ
• Neuro toxin is internalised into nerve endings by endocytosis
• ACh containing vesicles no longer fuse with the membrane
• ACh release into synaptic cleft is inhibited
• Collateral axonal sprouts develop & a new sprout develops a new NMJ
• Eventually the original NMJ resumes function so the overall pathophysiology of the muscle is not altered by multiple injections

Question 10

What effect does botox have on interventions for spasticity management?

Answer 10

• Less spasticity
• Stretches more effective
• Functional/task training more effective
• Strengthening more effective
• Able to work gastrocs through full range

Question 11

What are the advantages of botox?

Answer 11

• Reversible
• ‘Window of opportunity’ to learn motor patterns with reduced influence of spasticity
• Can be repeated multiple times
• Minimal side effects
• Evidence suggesting that it ‘allows’ the muscle to grow

Question 12

What are the limitations of botox?

Answer 12

• Number of muscle groups that can be injected
• Only reduces spasticity in injected muscle groups (doesn’t reduce contracture)
• Dependent on appropriate muscle selection
• Some muscle groups are too difficult to access
• Only lasts a few months

Question 13

How is botox administered?

Answer 13

• Injection into motor point of muscle
• US to locate injection site is now mandatory
• E-stim can also be used to localize in muscle
• Varies from sedation, nitrous oxide, general anaesthetic

Question 14

What does the physio assessment prior to botox include?

Answer 14

• Movement skills & functional activities including gait
• Determine what is impacting on movement
• Biomechanical Ax (R1/R2)
• Spasticity, strength & selective motor control

Question 15

When assessing R1/R2, what degree of difference is considered to be a key indicator for the effectiveness of botox to improve function?

Answer 15

30 degrees

Question 16

What treatments can occur post botox injection?

Answer 16

• Often used in conjunction with serial casting & splinting to maximise muscle length
• Gait re-training & functional movement skills
• Strength training
• Selective motor control
• Biomechanical Ax (R1/R2)

Question 17

What are the dose limitations of botox?

Answer 17

• More required for larger muscles (i.e. LL > UL)
• Usually restricts to 4 major LL muscles
• Repeat injections at 6-12/12

Question 18

What is the most common oral medication used for spasticity?

Answer 18

Baclofen

Question 19

What are the effects of oral medications?

Answer 19

• Total body effect
• Can cause drowsiness
• When effective should improve energy (as no longer working against spasticity)
• May be used with botox injections

Question 20

What are the characteristics of intrathecal baclofen?

Answer 20

• Delivered via a pump directly into the spinal cord through a catheter
• Effect is below level of catheter only
• Pre-pump trial using bolus injection
• Management issues for refilling of pump and monitoring

Question 21

What does the physio management of baclofen treatment involve?

Answer 21

• Monitoring of effect of drug therapy & side effects
• Continue with usual physio routine but expect improvement in child’s abilities
• ITB usually for GMFCS 4 & 5
• Posture in walkers, standing frames, wheelchairs checked

Question 22

What is Selective Dorsal Rhizotomy?

Answer 22

• Permanent neurosurgical technique being used to treat spasticity in the lower limbs
• Sensory neuron nerve rootlets are severed
• Prevents reflex cycle

Question 23

What does the surgery for SDR involve?

Answer 23

• Sensory nerve roots that are overactive are identified by e-stim & then cut
• Number of nerve roots cut is dependent on the severity of spasticity
• Major irreversible surgery requiring general anaesthetic
• Done at a very young age, but very rare

Question 24

What are the indicators for SDR?

Answer 24

• Six and under
• Straight
• Spasticity
• Strong
• Social
• Supported
• Must be able to follow instructions & comply with program

Question 25

What are the CIs for SDR?

Answer 25

• Mixed type (athetoid, dystonia)
• Contractures
• Previous surgery
• Hip displacement

Question 26

What is another reason patients for SDR are carefully selected?

Answer 26

Removing the spasticity may unmask another underlying problem such as dystonia &/or weakness

Question 27

What physio is done post SDR surgery?

Answer 27

• Intense physio & home treatment for 12 months
• Initially very week
• Does not eliminate need for bony surgery at a later time