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Pediatrics Lecture 2 > Medical Management of Spasticity > Flashcards

Medical Management of Spasticity Flashcards

1
Q

What disorders are typically associated with spasticity?

A

CP, TBI, CVA, SCI, Neurodegenerative disorders, myelodysplasia (spina bifida)

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2
Q

What is spasticity?

A

Disorder of muscle tone characterized by velocity dependent increase in resistance of a limb at rest to externally imposed joint motion

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3
Q

Give the proposed theory for why spasticity occurs.

A

It may be due to lack of descending inhibitory input to alpha motor neuron (neuron always excited)

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4
Q

Why would spasticity be considered helpful to children?

A

holds child up, good for standing pivot, muscle being activated so muscle mass increases and skin breakdown, swelling, and blood clots are decreased

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5
Q

Spasticity is harmful because of what?

A

Impairs typical volitional function, increased risk of contracture, increased metabolic requirements

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6
Q

Give the 4 oral medications for decreasing spasticity?

A

Baclofen (#1)
Dantrolene
Tizanidine
Benzodiazepenes

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7
Q

What is the purpose of oral medications and what are some common side effects of the medications?

A

Achieves generalized decrease in muscle tone (not just one muscle)

Side Effects
Sedation, confusion, dizziness, decreased cognition, increased incontinence

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8
Q

What are the two types of injections and where are they inserted?

A

Botulinum Toxin goes straight to the muscles

Phenol Injections of benzyl alcohol go perineurally

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9
Q

Botox is a protein that produces what kind of outcome?

A

Binds to neuromuscular junction inhibiting acetylcholine release which results in an inhibition of muscle contractions

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10
Q

Why would Botox wear off and how long does that process take?

A

It wears off because the neuromuscular junction remodels. This process takes about 3-6 months

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11
Q

Why does Botox not completely inhibit the muscle it is injected in to?

A

The muscles are so large that it will not cover all the muscle fibers.

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12
Q

What is the best time to start treating a patient who has had recent bots injections?

A

10-14 days: This is the peak time

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13
Q

Why would a therapist recommend a patient look into Botox for treatment of spasticity?

A

Decreases spasticity and painful spasms; decrease post-sx pain; Improve UE function; improve ambulation; facilitate bracing, positioning, and therapy; commonly used in conjunction with serial casting

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14
Q

What is the cytotoxic effect of phenol neurolysis?

A

Demyelination and Wallerian degeneration

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15
Q

Give the advantages and disadvantages of phenol neurolysis.

A

Advantages: Lasts 9-15 months, cheaper, immediate effect

Disadvantages: Cooperative patient or conscoius sedation (painful), technically difficult to localize motor nerve, time consuming

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16
Q

What are some of the risks associated with phenol neurolysis?

A

Decreased sensation, vascular and skin side effects

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17
Q

An Intrathecal baclofen pump is placed where?

A

The pump and catheter are placed in the body, intrathecally at the specific level of the spine based on the child’s spasticity

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18
Q

How are patients chosen to get a intrathecal baclofen pump?

A

Over 2 years old, usually over 25 lbs, spastic quad/di/hemi/tri- plegic, non-ambulatory or ambulatory

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19
Q

Give some reasons that patients may choose oral baclofen over an intrathecal baclofen pump.

A
  1. Low blood brain barrier with high systemic absorption and low CNS absorption
  2. Lack of preferential spinal cord distribution
  3. Some pts with unacceptable side effects
  4. 60 mg dose
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20
Q

Why would a patient choose an ITB pump over oral baclofen?

A
  1. Delivered directly to CSF
  2. Potential for fewer systemic side effects
  3. Greater results
  4. Lower doses (600 mcg the most per day)
21
Q

Name the three portions of the ITB pump.

A
  1. Pump: gives meds at programmable rate
  2. Catheter: delivers medicine to intrathecal space
  3. Programmer: Allows for dosing
22
Q

What are some of the issues that can be found with ITB pump?

A

Trial bolus of baclofen inntrthecally, refill every 3-6 months, dosing takes weeks or months

23
Q

What risks are associated with ITB pump implantation?

A

Side Effects: Hypotonia, HA, dizziness, constipation
Overdose: respiratory depression, reversible coma, LOC, due to pump malfunction and catheter breakage or poor programming
Infection due to surgery

24
Q

What does a selective dorsal rhizotomy do to the nerve?

A

Splices dorsal nerve afferent rootlets

25
Q

An SDR causes what to happen?

A

Interrupts afferent pathway to decrease the ‘noise’ to efferent nerves therefore decreasing spasticity and increasing wanted movements

26
Q

Patient are selected based on these criteria:

A

1) At least 4 years old (6-7 normal)
2) Must be ambulatory without contribution of spasticity
3) Committed involved family

27
Q

Give the pros and cons for an SDR.

A

Pros: no implanted pumps inside body, clinically proven to decrease spasticity

Cons: Permanent, may have decreased sensation, 8-12 weeks in rehab hospital and 1 year in outpatient therapy

28
Q

What are the differences in an SDR and an ITB

A
  1. SDR improves LE function more than ITB (both increase though)
  2. Less orthopedic procedures in children with SDR
  3. SDR permanent and ITB replaced every 5 years
  4. with SDR child must be ambulatory
  5. ITB can be younger patients
29
Q

What similarities do SDR and ITB have?

A
  1. Pt and parent satisfaction = for both
  2. Both require intensive and lengthy PT after procedure
  3. Both result in improved function and decreased impairment, better UE function
30
Q

How is PT involved after surgery with SDR and ITB?

A

Baseline before and after

Strengthening: Trunk- foundation for all extremities to move, LE-proximal stability first; hip and knee extension

31
Q

T/F Most skeletal deformities are present at birth

A

False: most are NOT

32
Q

Deformities still occur in children in spite of?

A

Early and aggressive management

33
Q

Muscles will grow in response to what outside factor?

A

Stretching

34
Q

What will muscle imbalance mean for the child?

A

Contractures and lever arm dysfunction

35
Q

What may delay or eliminate the need for orthopedic surgeries for milder cases?

A

Early intervention and anti-spasticity meds or surgeries

36
Q

At what age would an orthopedist consider a surgery?

A

At least 5 years old

37
Q

There are 6 common orthopedic surgeries due to spasticity. Name them

A

1) Lengthening procedures (tenotomy)
2) Muscle Transfers
3) Correction of Lever Arm Dysfunction
4) Joint Reconstruction
5) Osteotomies
6) Scoliosis Correction

38
Q

What is a tenotomy and what 3 types of surgeries are associated with lengthening procedures?

A

Muscle or tendon lengthening by surgically cutting fascia, muscle fibers, and tendons

1) Tendo- Achilles Lengthening: Decreased DF or increased PF, have short BK cast
2) Medial HS: HS shortening, decreased popliteal angle , crouched, or posterior pelvic tilt, will have long leg cast
3) ADD lengthening: Scissor gait, have a hip spica after

39
Q

What are the two types of Muscle transfers?

A

Rectus Femoris Transfer (RFT) and Split Anterior Tibialis Transfer (SPLAT)

40
Q

What is involved with a RFT?

A

Transfer rectus (only) posteriorly connecting to semitendinosus
Increases knee flexion during gait
Indications: stiff knee, toe drag, or tripping, positive prone knee bend test

41
Q

Describe why a SPLAT is necessary and what it helps.

A

Split AT in two; keep original attachment, other part to peroneals
Increases eversion strength to keep foot in neutral
Indications: Inverted gait; WB on lateral edge of foot in PF

42
Q

Describe the surgery associated with correction of lever arm dysfunction.

A

Patellar Tendon Advancement: Patellar tendon reattached distal to tibial tuberosity
Increases function of quad to extend knee
Indications: Patella alta

43
Q

A joint reconstruction is indicated because of? What does it help?

A

Acetabuloplasty
Increase curvature of acetabulum to increase convergence of femur in joint
Indications: frequent hip subluxes/dislocations

44
Q

What is a varus derotational osteotomy?

A

Derotation of femur to decrease excessive ante version
This will decrease angle of inclination to normal
Indications: Intoeing; decreased angle of inclination; hip subluxation; frequently in conjunction with acetabuloplasty

45
Q

How would a valgus osteotomy be helpful?

A

Increases angle of inclination such that the femoral head does not sit in the acetabulum

Indications: non-ambulatory child with hip pain due to impingement

46
Q

What are the treatments and indications for a scoliosis correcting surgery?

A

Indications: greater than 40 degrees curvature (Cobb method); decreased UE function, respiratory function, noncompliance with bracing
Harrington Braces are rods implanted into spine
Current treatment helps with rotation and can have a telescoping rods that grow with the patient.

47
Q

What other surgeries are common to have with a SPLAT?

A

Gastroc, medial HS and ADD lengthening

Tibial Osteotomy

48
Q

Give the time frame and prescription for PT during these recovery times.

A

0-3 weeks: PROM, CPM; osteotomies- immobilizers and NWB transfers
3-6 weeks: out of immobilizers, PWB->FWB, AROM and PROM, strengthening
6-12 weeks: Increase strength and stretch, increase endurance
After 12 weeks: Gait training and stander, etc

Pediatrics Lecture 2 (4 decks)

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