Download CCCSpasticity Nonaudio Guide v1

SPASTICITY Non-Audio Facilitator Guide
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Please allow 45 minutes for this session with an additional 10-15 minutes for discussion and questions
Below is a slide-by-slide guide with suggested discussion points. The slides are equipped with animations that
can be triggered when you see the word [click] in brackets.
Before facilitating this session, please thoroughly review these slides and notes and practice triggering the
animation.
SLIDE
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
DISCUSSION POINTS/NOTES
Spasticity
Describe the signs, symptoms and complications of
spasticity
Identify the patient with spasticity that is not optimally
managed
Summarize the different pharmacologic and nonpharmacologic treatment modalities
Plan a basic approach to managing spasticity in a patient
Medications
Intrathecal Baclofen
Identify the role of the consultant (PM&R) in helping with
management
Selective Rhizotomy
Chemodenervation
Summary
Identify the patient with baclofen withdrawal and initiate
management
By the end of this learning module you
should be able to:
[click] Describe the signs, symptoms and
complications of spasticity
[click] Identify the patient with spasticity
that is not optimally managed
[click] Summarize the different
pharmacologic and non-pharmacologic
teratment modalities
[click] Plan a basic approach to managing
spasticity in a patient
[click] Identify the role of the consultant in
helping with management
[click] Identify the patient with baclofen
withdrawal and initiate management
References & Resources
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Spasticity =
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Motor Disorder
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Velocity Dependent
The term “spasticity” is very commonly used
by clinicians, but often with meanings that
differ.
Spasticity is a motor disorder that is
characterized by a [click] velocity dependent
increase resistance to passive stretch.
Spasticity is a result of hyper-excitability of
the stretch reflex as one component of
upper motor neuron syndrome.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
The term spasticity is commonly misused by
clinicians [click].
[click] Spasticity is a velocity dependent
increase in tone because it is a stretch
sensitive phenomenon.
[click]Spasticity is not equivalent to upper
motor neuron signs because it is one
component of upper motor neuron signs.
Nor is it equivalent to muscle over-activity.
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Complex Care
Curriculum
Learning Objectives
Spasticity
Upper Motor Neuron Syndrome
A lesion of the corticospinal pathway
produces an upper motor neuron syndrome
featuring [click] positive and [click] negative
clinical signs.
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
[click] Positive signs are involuntary
phenomena characterized by muscle overactivity – leading to symptoms of spasticity,
clonus, flexor/extensor spasm, and hyperreflexia.
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
[click] Negative signs, in contrast, are
characterized by weakness, leading to loss of
normal voluntary motor control and
dexterity. Other symptoms include
paralysis, fatigability, and slowness of
movement.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
Spasticity
Brain Injury
– traumatic brain injury, cerebral palsy,
stroke, bacterial meningitis, encephalitis,
tumor, MS
Spasticity may result from a variety of
lesions at different locations, which can be
broadly characterized as [click] brain
injury,[click] spinal cord injury, [click]
neuromuscular injury, or [click] genetic
disorders and degenerative diseases.
Spinal Cord Injury
– tumor, infection, trauma, MS
Neuromuscular
– ALS, Friederich ataxia
Genetic disorders and degenerative diseases
– Sjogren-Larsson syndrome, Tay-Sachs
disease, and Rett syndrome
References & Resources
While the etiology of spasticity may vary,
much of the pediatric spasticity literature
focuses on cerebral palsy.
Cerebral palsy [click] is a group of disorders
of the development of movement and
posture causing activity limitations that are
attributed to non-progressive disturbances
in the developing fetal or infant brain.
A key teaching point [click] is that while the
central nervous system damage in cerebral
palsy is not progressive, the secondary
musculoskeletal pathology is progressive.
This diagram shows the progression of a
static CNS lesion to progressive
musculosketeletal deformity.
A central nervous system lesion that results
in [click] upper motor neuron syndrome may
be associated with positive symptoms such
as [click] spasticity and negative symptoms
such as [click] weakness.
Spasticity increases muscle stiffness, which
appears to [click] inhibit muscle growth, as
does lack of weight-bearing activity.
[click] Contractures may develop because
bone growth outpaces muscle growth.
[click] Bony torsion may be caused by
chronic spasticity and contracted muscletendon units on growing bone and
disordered biomechanics.
These factors may lead to [click] unstable,
deformed, and eventually [click] [click]
dislocated joints.
KEY POINT [click]: As a result, a static CNS
lesion may cause progressive deformities.
This is important to note because it
suggests, for instance, that children should
be repeatedly screened for joint dislocation
as they age.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Spasticity
Unmanaged spasticity may also be
associated with a number of problems and
can have a profound clinical impact. This list
is not exhaustive, but introduces some of
the clinical manifestations of poorly
controlled spasticity.
For example, [click] patients may have
impaired motor control from decreased
balance, coordination, or weakness.
Treatment Plan
Treatment Options
Medications
[click] Patients may have bowel and bladder
problems, like constipation or urinary
retention.
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
They may develop skeletal or skin
deformities, including contractures, joint
subluxation or dislocation, and scoliosis.
Immobility may lead to skin breakdown, and
subsequent pressure ulcers or wound
infections.
[click] Self-Esteem can also be effected, due
to poor self image, or inability to perform
activities of daily living.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
Spasticity
Muscle Tone
– Ashworth Scale
– Modified Ashworth Scale
A wide range of outcome measures exists
for assessing spasticity and the effectiveness
of the intervention.
The next few slides will show these scales in
more detail.
Muscle reaction at different velocity of
stretch
– Tardieu Scale
Range of Motion
Muscle Strength
Disability/Function
Overall Motor Function
References & Resources
The Ashworth Scale is a 5-point scoring
system used for the measurement of
muscle tone. The patient is examined in
a relaxed position while passive
movements to the limbs are made by the
practitioner. Resistance to passive
movement is graded on a scale ranging
from no increase in tone to limb rigidity
in flexion or extension. Although this
scale has not been validated, it is widely
used to assess spasticity (actually only
the muscle tone component of
spasticity), probably because it is easy to
use.
The modified Ashworth scale differs
from the original Ashworth scale in the
addition of a 1+ to differentiate the
catch that is felt in some patients when
limbs are passively moved. Although the
reliability of this scale has been
demonstrated for elbow flexors,
reliability at lower limb joints is not as
high. Additionally, the 1+ poses some
statistical problems in that the scale is no
longer ordinal values.
The Tardieu scale is based on velocity.
The benefit of all three of these scales is
to document exams in order to
determine disease progression as well as
effectiveness of treatment.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Observation of function
Identify movement disorder
Assess sensibility
Determine active and passive ROM
Evaluate spasticity, strength, and
reflexes
Evaluate posture, gait, and balance
The physical exam features to assess
spasticity including the following:
[click] Observation of function
[click] Identify movement disorder
[click] Assess sensibility
[click] Determine active and passive
range of motion
[click] Evaluate spasticity, strength, and
reflexes
[click] Evaluate posture, gait, and
balance
Summary
References & Resources
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Spasticity
Treatment Plan ↔ Patient Goals
In devising a treatment plan for patients
with spasticity, a central focus should be the
goals of treatment.
For example, does the patient have function
that we are working to improve? Is the goal
to improve ROM, gait, or purposeful
movements to improve function for the
patient?
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
For some patients, function is limited, so the
goals of treatment are to improve ease of
daily care. For example, an improvement in
position may help with daily cares, like
changing diapers or performing urinary
catherizations. An improvement in position
may also aid with skin integrity and reduce
pressure ulcers, as well as avoid deformities
or contractures that may lead to joint
dislocations and pain.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
While we want to broadly characterize
the goals of treatment, examples of
specific management goals are included
in this list.
[click] Decrease tone
[click] Increase range of motion
[click] Improve fit and utilization of
orthoses
[click] Decrease contractures
[click] Delay orthopedic surgery
[click] Improve position for care
[click] Improve function
[click] Decrease caregiver burden
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Factors
Drug formulation
Drug Frequency
Drug delivery
Side effects
Cost
Spasticity
Disease Factors
Generalized vs. Focal
Comorbidities
Chronicity
Prognosis
The choice of therapy in pediatric
spasticity is influenced by various
interlocking factors.
[click] Disease factors include the
distribution of spasticity (for example,
focal or generalized), comorbid
conditions such as seizures, as well as
chronicity and prognosis.
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Patient Factors
Patient and family motivation
Availability of services and resources
Compliance
[click] Treatment factors include drug
dosing, frequency, formulation, and
delivery, side effect profile, possible drug
interactions, a patient’s prior reaction to
a given treatment, the response to
previous treatments he or she may have
received, and cost.
And, of course, another key
consideration is [click] patient factors.
Specifically, patient and family
motivation as well as access to available
services, because some treatment will
require extensive therapy in order to see
an effect. compliance with treatment
and commitment to follow up is another
patient factor to consider.
Complex Care
Curriculum
Spasticity
Learning Objectives
Spasticity
Definition
Etiology &
Pathophysiology
Evaluate Patient:
Does spasticity present a
problem?
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
NO
No
treatment
Continual
re-assess
YES
Treatment Options
Medications
Patient and
Caregiver objectives
Functional
objectives
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Initiate comprehensive
spasticity management
program
Technical
objectives
The first step in the treatment decision is
to determine whether patients with
spasticity need to be treated. By
thinking about specific treatment goals,
we can decide if a patient needs to be
treated for his or her spasticity. As
mentioned earlier, the patient should be
evaluated to determine whether
spasticity significantly interferes with
functioning, such as gait, activities of
daily living, comfort, or caregiving, and
whether it may lead to musculoskeletal
deformity or problems with skin
integrity.
[click] If the answer is no, spasticity may
not need to be treated immediately.
However, periodic re-evaluation should
be performed to assess changing needs
as the child grows.
[click] If spasticity is interfering with
function or is likely to lead to
musculoskeletal deformity or other
consequences of spasticity, a thorough
determination of treatment goals should
be formulated in collaboration with the
patient and caregiver.
Technical goals may include reducing
tone and improving range of motion.
Functional goals may include improving
gait, hygiene, and pain.
A comprehensive management is then
undertaken, which may include a variety
of treatments enumerated on
subsequent slides. The treatment
program selected will depend on
functional goals, specific features of the
patient’s condition for example,
intellectual deficits. Treatment programs
should be re-evaluated periodically so
that alterations can be made according
to the growing child’s changing needs.
The spasticity management team is
made up of the patient and his or her
family/caregiver along with a group of
professionals across a range of
disciplines.
KEY POINT: The members of the team
are likely to change as the child ages,
needs evolve, and goals change [click].
For instance, a child 3 to 12 months of
age typically needs occupational and
physical therapy but not speech therapy,
orthoses, or neurosurgery. As children
age, they may be more likely to need
orthoses and surgical intervention.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
What is the Role of the Physiatrist?
Function at home and in the community
Orthoses and therapeutic equipment
Altered muscle tone
Facilitating the ability of the child and
family to set functional goals
Pediatric physiatrists play an important
role in the management and treatment
of patients with spasticity. For
example, pediatric physiatrist work to :
[click] improve age appropriate function
at home and in the community.
[click] They work to evaluate patients for
orthoses and other therapeutic
equipment, as well as [click] discuss
treatment options for managing muscle
tone. [click] They also work with the
patient and family to establish
appropriate treatment goals.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
As a general pediatrcian (either inpatient
or outpatient), it is important to think
about worrisome signs or symptoms that
should warrant concern and possible
referral to a physiatrist. This list can
include Developmental problems,
Muscle Tone problems, Pain, or
Dysautonomia.
In terms of [click] development,
indications for referral or consultation
include abnormal motor milestones,
persistent primitive reflexes and early
hand preference (less than 1 year of
age); in terms of muscle tone [click],
worrisome findings include spasticity,
hypotonia or hypertonia, decreased
range of motion of any joint, abnormal
posturing; in terms of pain [click],
patients who have neuropathic pain,
who have received an amputation, who
have persistent musculoskeletal pain and
those with wounds may benefit from
referral; finally, if you suspect [click]
dysautonomia, early consultation with a
physiatrist can be very helpful for the
patient.
[click] Treatment options for patients are
individualized based on goals.
[click] Therapy – PT/OT maintains range
of motion and prevents fixed
contractures. While this is a mainstay of
treatment, no matter how well or
frequently stretching is performed, some
children will nonetheless develop
contractures.
[click]Orthoses – Orthoses are braces
that provide support. A variety of
orthotic interventions are available to
promote stretching and reduce
contractures. Night-time splints may be
useful, or AFO (Ankle-foot-orthosis) are
common for equinus form.
[click] Casting may be used to gradually
restore range of motion to an involved
limb.
[click] Medications we will discuss in
more detail later in the presentation.
[click] Surgery – Despite the best
management, orthopedic surgery may
eventually be required. Heel cord
lengthening is the most common
procedure, along with hip realignment.
As expected, these procedures are more
common in children with higher Gross
Motor Function scores.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Surgical and
Pharmacologic
Treatment
Spasticity
General
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Reversible
Medications
Permanent
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Focal
Spasticity
This graphic classifies the available
treatments for pediatric spasticity along
two dimensions: whether they target
[click] focal or general spasticity and
whether their effects are [click]
permanent or reversible.
[click] Oral therapies and intrathecal
baclofen are reversible and target
general or regional spasticity.
[click] Selective dorsal rhizotomy is
general in its effects and irreversible.
This will be discussed in more detail later
in the module.
[click] Chemodenervation produces focal
effects that are reversible.
[click] Local corrective surgery is focal
(although it may have broad-ranging
effects on biomechanics and alignment)
and semi-permanent. Surgeries may
include tendon lengthening, tendon
transfer, or osteotomy
The treatment options that we will be
discussing in greater detail during this
presentation will be:
Oral medications
Intrathecal Baclofen
Selective Dorsal Rhizotomy
Chemodenervation
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
Most of the drugs used for the treatment
of spasticity affect the neurotransmittor
GABA, which inhibits the activity of nerve
cells in both the brain and spinal cord.
Baclofen is a drug that mimics the action
of GABA as a receptor agonist.
Benzodiazepines, including diazepam
and clonazepam, potentiate the effect of
GABA at the receptor.
Tizanidine (Zanaflex®) affects the
transmittor norepinephrine (also called
noradrenaline), mimicking its action at
the alpha-2 receptor.
Dantrolene acts at the muscle instead of
at nerve cells and inhibits the release of
calcium ions inside muscle cells, which
prevents them from contracting.
Trihexyphenidyl (Artane) acts as an
anticholinergic medication working on
central muscarinic receptors.
Oral medications are typically used to
achieve a generalized decrease in body
tone . Due to the systemic distribution
of oral medications, central side effects
are common. These include sedation (all
medications listed on this slide), nausea,
constipation, and weakness (particularly
with dantrolene). Tizanidine and
dantrolene may also lead to
hepatotoxicity . Trihexyphenidyl is
associated with anticholinergic side
effects including dry mouth.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Spasticity
This table is a general guide for dosing
with initial dosage and max per day.
Each medication should be started at the
lower end of the range, and titrated up
to balance the benefits and side effects
of each medication.
Higher doses of diazepam have been
used for spasticity management, but
should be done in consultation with your
local pediatric physiatrist.
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
As mentioned, sedation is a side effect
for all oral medications used to treat
spasticity. To balance the potential
benefits and side effects of each
medication, dosage should always begin
at the lower end and then be titrated
upward to a level that provides optimal
benefit.
KEY POINT: [click] An important
consideration is that withdrawal can
result in a lower threshold for seizures,
so all medications need to be tapered. If
a patient is made NPO, oral spasticity
medications need to be converted to IV
formulation, and often IV diazepam is
used since the other medications do not
have an IV form.
Oral Baclofen is often the initial
medication used in spasticity
management. [click] However, it is
important to know that the liquid
formulation of baclofen is not a standard
concentration, and is mixed at local
pharmacies. Without knowing the mg
dosage amount, you cannot infer a dose
based on the volume or mL.
[click] When prescribing or re-ordering
oral baclofen, the dose MUST be verified
to avoid fatal medication errors related
to baclofen.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Intrathecal
baclofen:
50x response
of oral
baclofen
Spasticity
Now I will discuss use of intrathecal
baclofen via pump. Baclofen is a GABA-
agonist that presynaptically inhibits
sensory afferents leading to a decrease
in reflexive motor neuron activation.
The baclofen is delivered directly to CSF
via a catheter from device in abdomen,
which limits systemic side effects and
provides greater response compared to
oral baclofen – [click] close to 50 times
the response of oral baclofen. As a
result, intrathecal baclofen may be
therapeutic at 1 to 2 % of the oral dose.
Long-term delivery of intrathecal
baclofen is achieved via a programmable
pump implanted into the anterior
abdominal wall, connected to a catheter
that runs subcutaneously to the lumbar
subarachnoid space. It is a peristatlic
pump with a battery life of 4 to 7 years,
and includes a reservoir for baclofen and
electronic controls for regulation by
telemetry. They are typically placed and
managed by pediatric neurosurgeons.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Spasticity
Who is a candidate?
Severe, generalized tone
Not successfully managed with oral
medications
Improvement with test dose of intrathecal
baclofen given via lumbar puncture
Medications
Intrathecal Baclofen
Selective Rhizotomy
Intrathecal baclofen has been found to
improve muscle tone of both the upper
and lower limbs, physical functioning,
and ease of caregiving.
Candidates include patient who [click]
have severe generalized spasticity, and
are [click] not successfully managed with
oral medications.
Prior to being implanted, patients are
challenged with a bolus of baclofen
injected intrathecally.
[click] Patients who respond with a
decrease in muscle tone are considered
candidates for pump implantation.
Chemodenervation
Summary
References & Resources
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
[click] The pros of this treatment
modality include GABA inhibition
without side effects in the brain and the
ability to program the pump to the
appropriate therapeutic dose.
[click] The cons of this treatment
modality include complications of the
device, which we will discuss more in the
next slide, as well as the maintenance of
the pump in terms of battery life and
refills.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
In general, complications with the pump
can be divided into two big categories –
mechanical and medical.
Mechanical problems include leak,
catheter migration, catheter kink or
disconnection. Problems with the
hardware may also increase the risk of
infection, including meningitis.
Medical problems include side effects of
overdose or problems with withdrawal.
Lethargy, sedation, and confusion may
result when doses are too high. If the
patient experiences withdrawal, this is
an emergency.
Selective Rhizotomy
Chemodenervation
Summary
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Late signs:
Hyperthermia
Seizures
Rhabdomyolysis
DIC
Altered Mental Status
Psychomotor agitation
Respiratory Distress
Multisystem Organ Failure
Early signs:
Pruritis
Dysphoria
Irritability
Spasticity
Tachycardia
Fever
Hypertension
Respiratory Distress
Intrathecal baclofen withdrawal can be
fatal.
When caring for a patient with this
treatment modality, it is important to
discuss the early and late symptoms of
baclofen withdrawal with the care team
and nursing staff. [click] Early symptoms
include pruritis, dysphoria, irritability,
increased spasticity, tachycardia, fever,
changes in BP, respiratory distress.
[click] Late symptoms include severe
hyperthermia, seizures, rhabdomyolysis,
DIC, altered mental status, psychomotor
agitation, respiratory distress,
multisystem failure, death.
If you are concerned that the intrathecal
pump is failing, [click] patient should be
immediately treated with high-dose oral
baclofen or IV diazepam. Infusion of
intrathecal baclofen through a lumbar
drain is another option
Xrays are done to assess pump and
catheter placement.
Spiral CT will assess for catheter
placement, leakage, and kinking of the
tubing.
The most important consideration is to
call Neurosurgery as soon as possible!
Selective dorsal rhizotomy is a procedure
in which selected sensory roots in the L2
to S2 regions are transected. The logic
behind this procedure is to interrupt the
reflex loops that are causing spasticity.
To isolate these nerves, electrical
stimulation of sensory roots is
performed while recording
electromyographic activity in the leg
muscles to determine which of the
rootlets are associated with the most
abnormal pattern of sensory feedback.
These roots are targeted, and then
destroyed.
A maximum of 50% of sensory roots are
transected at any spinal level. Late
complications of selective dorsal
rhizotomy may include motor weakness,
sensory loss, urinary incontinence, and
spinal problems.
Good candidates are patients with pure
spasticity diplegia. Appropriate patients
are ambulatory without fixed
contractures.
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Spasticity
Who is a Good Candidate?
Ages between 4 and 7 years
“Pure” spasticity
Ambulatory
Absence of fixed contractures
Cooperation with intensive therapy
Candidates are generally between [click]
4 and 7 years of age with [click] pure
spasticity, often spastic diplegia.
Patients are [click] ambulatory or have
potential to ambulate with [click] no
fixed contractures. An important
consideration is the [click] ability and
motivation to cooperate with intensive
therapy after the surgical procedure.
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
This is a movie showing a patient’s
response to selective dorsal rhizotomy.
Complex Care
Curriculum
Spasticity
Chemodenervation with botulinum toxin
and intramuscular neurolysis with
phenol have been used to treat focal
spasticity.
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Botulinum toxin type A temporary blocks
presynaptic release of acetylcholine that
results in selective motor denervation at
the neuromuscular junction. The onset
of action is 24 to 72 hours. The duration
of action is 6 to 12 weeks. However
clinical outcomes can be seen for 3 to 6
months post treatment. It is easy to
inject the neurotoxin from a technical
stand point. The medication has a very
high cost.
Chemodenervation
Summary
References & Resources
Phenol causes non-selective chemical
neurolysis in the injected nerve. The
onset of action is less than one hour. The
duration of action is 2 to 36 months.
Phenol is more difficult to inject than
botulinum toxin since localization of the
nerve is required. Potential side effects
are dysesthesia and skin necrosis. Phenol
has a very low cost.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Chemodenervation and intramuscular
neurolysis have several advantages. The
treatment is minimally invasive and can
be repeated safely. As a result of the
treatment, decreased muscle tone and
increased range of motion may allow the
patients to learn normal movement
pattern, mimic surgical outcomes, permit
age-selective timing of surgery, and
improve positioning and ease of daily
care.
Disadvantages of the treatment are
decreased functional tone that may
cause increase in assistance with
transfers, mobility, and activities of daily
living, high cost of botulinum toxin, and
limited total dose of neurotoxin that can
be used based on the body weight.
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
The results of the treatment with
botulinum toxin and phenol are
temporary that could be considered as
an advantage but also as a disadvantage
of the treatment.
Complex Care
Curriculum
Spasticity
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Who is a Good Candidate?
Focal increase in muscle tone
Absence of fixed contractures
Absence of bony/joint problems
No underlying bleeding disorder
Proper patient selection for
chemodenervation is very important.
Good candidates for the treatment are
patients with focal increase in muscle
tone, patients with specific functional
goals or goals in improvement in
positioning, ease of daily care, and
orthoses tolerance. This type of
treatment may not be appropriate
and/or effective for patients who have
generalized increase in muscle tone,
fixed contractures, joint instability, bony
torsion, or bleeding disorders.
Complex Care
Curriculum
Learning Objectives
Spasticity
Timing of Botulinum Treatment
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Intervention with botulinum toxin type A
may have different benefits depending
on the age of the child. Treatment during
the dynamic phase of motor
development may maximize chance of
disease modification.
Treatment during the early years may
allow postponement, simplification, or
even avoidance of surgery.
Treatment during later years may
provide pain relief, improved ease of
care, attainment of goals such as sitting
or standing.
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Summary points from the module:
Complex Care
Curriculum
Learning Objectives
Definition
Etiology &
Pathophysiology
Impact of Spasticity &
Outcome Measures
Exam Features
Treatment Plan
Treatment Options
Medications
Intrathecal Baclofen
Selective Rhizotomy
Chemodenervation
Summary
References & Resources
Spasticity
Spasticity = 1 component of the UMN
syndrome
Spasticity = velocity dependent increased
resistance to passive stretch
Underlying lesion is static, but
musculoskeletal pathology is progressive
Treatment plan is not “one-size fits all”, but
should be customized to patient’s goals
Most spasticity medications CANNOT be
stopped abruptly. Should be weaned to
avoid seizures, or switched to IV if patient is
NPO.