Microsoft powerpoint - seth spasticity white orlando 2009.ppt

The Management of Spasticity;
The Evaluation and Treatment of
An Interdisciplinary Approach
Spasticity in Adults with ND/ID
• Decrease spasticity
• Infection (including urinary-tract)
• Improve functional ability and independence
• Constipation
• Decrease pain associated with spasticity
• Reflux
• Prevent or decrease incidence of contractures
• Decubitus ulcers
• Improve ambulation
• Stress
• Facilitate hygiene
• Ease rehabilitation procedures
• Anxiety
• Save caregivers’ time
• Changes in underlying disease state (e.g.,
Cervical Spondylosis with Spinal Cord
Compression)
Spasticity in Adults Living in a
Spectrum of Care for
Developmental Center
Management of Spasticity
• Identify specific functional goals before
initiating spasticity tx
(Intrathecal
of Spasticity
Baclofen Therapy)
• Found 35% of residents had spasticity
Rehabilitation
• Multidisciplinary team approach
• Improved QOL/ADL
Injection
Orthopedic
Treatments
Neurosurgical
Treatments
A. Pfister, BA, H. Taylor, MD, D. Charles, MD Arch Phys Med Rehab Vol 84, Dec 2003 Oral Medications
Systemic Medications
Most common:
LD/ADHD/Processing
• Baclofen (Lioresal®)
Emotional/psychiatric
• Diazepam (Valium®)
• Tizanidine (Zanaflex®)
Epilepsy
• Dantrolene sodium (Dantrium®)
Cognitive Impairment
Comorbidities in ND/ID
Orthopedic Surgeries
Soft Tissue Procedures
“All substances are
• Tenotomy
poisons; there is
• Tendon lengthening
none which is not
a poison. The right
• Myotomy
dose differentiates
• Tendon transfers
a poison from a
remedy.”
Neurosurgeries
Surgical Treatments
Botulinum Toxin
Neurodestructive Procedures
• Botulinum Toxin Type A
injected into the muscle
• Neurectomy
• Interferes with release of
• Myelotomy
acetylcholine at the
neuromuscular junction
• Rhizotomy
• No systemic effect
• Cordectomy
• May be administered
• Selective Dorsal Rhizotomy
without anesthesia
• EMG guidance for
localization
– Potential for significant morbidity from dysesthesia / • Results typically last 3-6
ITB™ Therapy
• Can be administered without anesthesia
Used to treat individuals with severe spasticity • No systemic effect
– diffuses readily into the muscle
• Cerebral palsy
• Facilitates treatment goals
• Effects are local and dose-dependent
• Brain injury
• Can be used with other therapies
• Brain attack (stroke)
– including ITB Therapy
• Spinal cord injury
• Maximum up to 600U/visit
• Multiple sclerosis
Delivers a liquid form of baclofen (Lioresal®
Intrathecal) directly into the intrathecal space where
fluid flows around the spinal cord.
Relieves spasticity with a small amount of drug
delivered via a programmable pump to where it is
most effective in the spinal fluid.
FDA approved
• Acts as GABA – receptor agonist
• Patients must demonstrate a positive
– GABA (gamma-amino butyric acid) is an inhibitory CNS
response to the screening test
neurotransmitter
– Two receptor types (GABA and GABA )
• Patients with spasticity of spinal origin:
• Mechanism of action is probably presynaptic
– are unresponsive to oral antispasmodics
inhibition
– and/or experience unacceptable side effects at
– Inhibits release of calcium into presynaptic terminals
– Thereby impedes release of excitatory neurotransmitters
effective doses of oral baclofen
• Baclofen is delivered directly into CSF in intrathecal
• Patients with spasticity of cerebral origin
must be one year post brain injury to be
considered for ITB Therapy
• Positive responses to screening trials:
– 86% cerebral origin
• Reversible
– 97% spinal cord origin
• Potentially fewer systemic side effects
• Upper and lower extremity effects noted
• Programmable
• Improvements for patients with functional goals &
– allows dose titration to give optimal benefit
for patients with goals of improving comfort and
ease of care
• Effective in reducing spasticity
– upper and lower extremities1
– cerebral and spinal origin
1 Penn, Richard D, MD, Savoy, Suzanne M., MNS, Corcos, Daniel, et al., Intrathecal Baclofen for Severe Spinal
Spasticity, New England Journal of Medicine 320:1517-1521, 1989.
(Albright et al, 1991; Albright et al, 1995; Penn et al, 1989; Medtronic data on file) • Step 1: Screening Test
• The most common side effects include loose
• Step 2: Surgical Procedure
muscles, drowsiness, nausea/vomiting headache, and
dizziness.
• Step 3: Therapy Maintenance
• Overdose, although rare, could lead to respiratory
depression, loss of consciousness, reversible coma,
and in extreme cases, may be life-threatening.
• Complications when they occur are usually surgically
related.
• Abrupt discontinuation can result in high fever,
altered mental status, returned spasticity, and muscle
rigidity, and in rare cases has been fatal.
• Physical Therapy
• Occupational Therapy
• Speech-Language Therapy
SynchroMed EL
• Orthotics
• Adaptive Equipment
• Assistive Technology
Console Programmer
Rehabilitation Therapy
Rehabilitation: Considerations
• Stretching
• Cryotherapy
• Decrease positive signs
• Casting
• Hydrotherapy
– Spasticity
• Orthoses
• EMG biofeedback
– Contracture
• Positioning
• Electrical
• Improve negative signs
– Lack of Strength
• Weight bearing
stimulation
– Lack of Motor Control
• Rotary movements
• Vibration of the
– Lack of Balance
antagonist
Physical Therapy
Occupational Therapy
• Strengthening
• Fine motor skills
– Exercise, functional electrical stimulation
• Handwriting
• Gross motor skills
– Biofeedback
• Mobility
– Transfers, gait training, transitional movements
• Balance
– Ankle and hip strategies
• Activities of daily living (ADLs)
Synergistic Model of Spasticity Management Orthopedic
Rehabilitative
Neurologist
-Physiatry
-Physical Therapy
-Occupational Therapy
Physician
Neurosurgeon
Anesthesiologist
Care Staff
• Spasticity is a very common under appreciated
complication in those with ND/ID
• Many negative potential health consequences can
be attributed to spasticity
• There are several treatment options which need
to be individualized for each patient
• Assess patient function and potential to benefit
from spasticity therapy
• Set realistic goals for spasticity therapy
• The various treatments are synergistic with each
• The treatment of spasticity requires a team
approach
• Educate patients, families, and caregivers

Source: http://ddna.org/downloads/2009manual/keller_6.pdf