Spasticity Management in Cerebral Palsy

Question 1

What are the three management methods for spasticity?

Answer 1

1. Botulinum Neurotoxin Type A (BNTxA) injections
2. Oral medications and ITB
3. Selective dorsal rhizotomy

Question 2

What does BTX-A at the neuromuscular juunction?

Answer 2

Injection results in a reversible blockade of ACh release at the NMJ

Question 3

What is spasticity management aiming to assist in GMFCS I-III and IV-V children?

Answer 3

I-III: improve gait, improve sitting balance and function

IV-V: facilitate hygiene, improve sitting posture

Question 4

What are the goals for spasticity management?

Answer 4

• Facilitate orthotic management
• Continue conservatiev management until gait is mature
• Evaluating short term functional gain to provide information 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 5

What populations has BTX-A injection use been approved for in Australia?

Answer 5

• Equinous in 2-16 year old CP
• Focal spasticity >12 year olds
• Spasmodic torticollis

Question 6

What are the advantages of BTX-A injections?

Answer 6

• Reversible
• Opportunity for children 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 7

What are the limitations of BTX-A injections?

Answer 7

• Number of muscle groups that can be injected at once
• Only reduces spasticity in injected muscle groups (does not reduce contracture)
• Dependent on appropriate muscle selection
• Accessibility of significant muscle groups
• Effect only lasts a few months

Question 8

What are the dose limitations for BTX-A?

Answer 8

Lower Limb: 2 to 4U/Kg per muscle
Upper Limb: I to 2U/Kg per muscle
16U/Kg total – maximum 400 units

Question 9

How are BTX-A injections administered?

Answer 9

• Injection into motor point of muscle
• Ultrasound to locate injection site
• Electrical stimulation may be used to localise muscle
• Varies from sedation, nitrous oxide and general anaesthetic

Question 10

What is the most common oral medication for the treatment of spasticity in CP? What can it be used in conjunction with?

Answer 10

Baclofen. Can be used in conjunction with BTX-A injections

Question 11

How is a intrathecal baclofen (ITB) administered? What area does it effect?

Answer 11

Delivered via a pump directly into the spinal cord through a catheter. Effect is below level of catheter only

Question 12

What is a selective dorsal rhizotomy?

Answer 12

A neurological technique used to treat spasticity in the lower limbs

Question 13

What does a selective dorsal rhizotomy involve?

Answer 13

The sensory nerve roots which are overactive are identified by electrical stimulation and then cut leaving the others intact. The number of nerve roots cut is dependent on the severity of spasticity.
This procedure is irreversible.

Question 14

What are the six indicators (6S) for a selective dorsal rhizotomy?

Answer 14

• Six years and under
• Straight
• Spasticity
• Strong
• Social
• Supported

Question 15

What are the contraindications for a selective dorsal rhizotomy?

Answer 15

• Mixed type of cerebral palsy
• Contractures
• Previous surgery
• Hip displacement