Paediatric Spasticity and its management

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					               Paediatric Spasticity
               and its management

Surendra Pandey
Consultant Paediatrician

Regional SpR Training Session, Newcastle

January 2010
Next Hour …….
   What is Spasticity?
     Definition
     Stretch reflex
   Why
     Aetiology
   Consequences
     Good
     Bad
     Ugly
   Measurement
     Clinical
   Management
What is Spasticity

Lance (1980)
“Spasticity is a motor disorder characterized by a velocity dependent
   increase in tonic stretch reflexes (muscle tone) with exaggerated
   tendon jerks, resulting from hyper-excitability of stretch reflex, as
   one component of the upper motor neurone syndrome”.

Spasticity is a constant and unwanted contraction of one or more
  muscle group as a result of brain damage.3

   Cerebral Palsy

   Brain Trauma/stroke

   Familial spastic paraplegia

   Spino cerebellar degeneration

   Neuro-metabolic disorder

   Chromosomal syndromes
Consequences of spasticity


 > Power

 > Mobility

   Spasm
   Pain
   Difficulties in care
       Washing
       Bathing
       Dressing
       Nappies
   Impaired self function
       Reaching
       Transferring
       Sitting - walking

   Disfigurement
   Contractures
   Fibrosis → Atrophy
   Peripheral neuropathy
   Heterotopic ossification
   Joint subluxation
   Dislocation
Clinical Measurement

Two Scales

   Ashworth (modified)

   Tardieu Scale
Ashworth                        Modified Ashworth
Score                           Score
1   No increase in tone         0    No increase in tone
2   Slight increase in tone     1    Slight increase in tone
    with a „catch‟              1+   Slight increase in tone
3   Marked increase in tone          with catch followed by
    but affected part moved          resistance
    easily                      2    More marked increase
                                     in tone through most of
4   Considerable increase in         ROM
    tone; passive movement
                                3    Considerable increase
    difficult                        in muscle tone. Passive
5   Affected part(s) rigid in        movement difficult
    flexion                     4    Affected part rigid in
Tardieu Scale (1954)
0 No resistance throughout the course of passive

1   Slight resistance throughout the course of the passive
    movement with no catch

2   Clear catch at a precise angle interrupting the passive
    movement followed by release

3   Fatigable clonus, less than 10 seconds when
    maintaining the pressure

4   Unfatigable clonus, more than 10 seconds
   Observation
   Physio/OT
   Orthotics/Casting (serial, fixed)
   Oral medicines
       Baclofen
       Diazepam
       Tizanidine
       Dantrolene sodium
       Clonidine, Gabapentin, Tiagabine
   IM Injections
       Botulinum Toxin A
   Neurosurgical procedures
    -  Phenol
    -  Selective Dorsal Rizotomy
    -  Intrathecal Baclofen
    -  Sterotactic neurosurgery
    -  Deep brain stimulation

   Others
    -  Electrical stimulation of muscle
    -  Transcranial magnetic stimulation
    -  Neuroblast implantation
Drug          Mechanism of Action           Side effects

Diazepam     Increase GABA affinity for      Sedation,
             GABAa Receptors                 dependence

Baclofen     GABAa Receptor Agonist          Sedation,

Tizanidine   Alpha 2 Agonist                 Sympatholytic

Dantrolene Na Prevents calcium release       Nausea
              from sarcoplasmic reticulum
            ITB      SDR

        Orthopaedic surgery

         Neurolytic Blocks

           Oral treatment

PT/OT                Bracing/Casting

 Traditional “Pyramidal” Approach
Take Home Messages

   Spasticity may be beneficial to treat

   Selection of patient – team

   Be aware of other components of UMN syndromes

   Management of spasticity difficult

   No cure as yet

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