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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
An SDR causes what to happen?
Interrupts afferent pathway to decrease the 'noise' to efferent nerves therefore decreasing spasticity and increasing wanted movements
26
Patient are selected based on these criteria:
1) At least 4 years old (6-7 normal) 2) Must be ambulatory without contribution of spasticity 3) Committed involved family
27
Give the pros and cons for an SDR.
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
What are the differences in an SDR and an ITB
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
What similarities do SDR and ITB have?
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
How is PT involved after surgery with SDR and ITB?
Baseline before and after | Strengthening: Trunk- foundation for all extremities to move, LE-proximal stability first; hip and knee extension
31
T/F Most skeletal deformities are present at birth
False: most are NOT
32
Deformities still occur in children in spite of?
Early and aggressive management
33
Muscles will grow in response to what outside factor?
Stretching
34
What will muscle imbalance mean for the child?
Contractures and lever arm dysfunction
35
What may delay or eliminate the need for orthopedic surgeries for milder cases?
Early intervention and anti-spasticity meds or surgeries
36
At what age would an orthopedist consider a surgery?
At least 5 years old
37
There are 6 common orthopedic surgeries due to spasticity. Name them
1) Lengthening procedures (tenotomy) 2) Muscle Transfers 3) Correction of Lever Arm Dysfunction 4) Joint Reconstruction 5) Osteotomies 6) Scoliosis Correction
38
What is a tenotomy and what 3 types of surgeries are associated with lengthening procedures?
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
What are the two types of Muscle transfers?
Rectus Femoris Transfer (RFT) and Split Anterior Tibialis Transfer (SPLAT)
40
What is involved with a RFT?
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
Describe why a SPLAT is necessary and what it helps.
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
Describe the surgery associated with correction of lever arm dysfunction.
Patellar Tendon Advancement: Patellar tendon reattached distal to tibial tuberosity Increases function of quad to extend knee Indications: Patella alta
43
A joint reconstruction is indicated because of? What does it help?
Acetabuloplasty Increase curvature of acetabulum to increase convergence of femur in joint Indications: frequent hip subluxes/dislocations
44
What is a varus derotational osteotomy?
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
How would a valgus osteotomy be helpful?
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
What are the treatments and indications for a scoliosis correcting surgery?
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
What other surgeries are common to have with a SPLAT?
Gastroc, medial HS and ADD lengthening Tibial Osteotomy
48
Give the time frame and prescription for PT during these recovery times.
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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