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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

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