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
There is no doubt that antibiotics play a vital role in the treatment of many animal diseases. However, like many aspects of agriculture, there is increasing pressure from outside interestgroups to restrict their use in food producing animals. To date, veterinarians and their clientshave access to a wide range of effective drugs. If these drugs are used judiciously andappropriately, there should b
Mammogram Waiver for Testosterone and/or Estradiol Pellet Therapy I, _____________________________________, voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone and/or estradiol pel et therapy, even though I am not current on my yearly mammogram. I understand that such therapy is controversial and that many doctors believe that estradiol replacement in my
Rehabilitation Therapy