While spasticity can not be cured, some of the problems associated with spasticity can be cared for in a number of ways. Our goal in caring for a child with spasticity is to maximize his functional potential.
Our Spasticity program at Children's at Scottish Rite offers a multidisciplinary approach aimed at reducing and controlling spasticity in children. Each child is individually evaluated by a neurologist, a neurosurgeon, an orthopaedic surgeon and a physical therapist. The specialists then discuss which treatment protocol or combination of treatment protocols would best benefit each child. Treatment protocols include:
Each of these treatment options is supported by a comprehensive physical rehabilitation therapy program to maximize results for each child.
The Role of Physical and Occupational Therapy
As more treatment protocols become available for children with spasticity, the importance of rehabilitative therapies has expanded. At Children’s Healthcare of Atlanta, therapists work with neurologists, neurosurgeons and orthopaedic surgeons in evaluating the best treatment program for each child with spasticity. Within each individualized treatment plan, physical and occupational therapy are essential in maximizing the benefits obtained.
Baclofen Pump Therapy
contributed by Joanne S. Janas, M.D. and William R. Boydston, M.D., Ph.D.
Baclofen is a drug used to relax muscles. Large doses of baclofen taken by mouth can produce unacceptable sedation.
The baclofen pump delivers the drug only to the nerves controlling the child's muscles. The pump is a mechanical device surgically implanted on the abdominal wall. The pump is connected to a small tube implanted in the spinal canal. The pump delivers a specific amount of baclofen to the nerves in the spinal cord. The dosage can be adjusted non-surgically by a neurologist.
Before surgical implantation at Children's Healthcare of Atlanta, patients undergo a drug trial to evaluate the potential effectiveness of the pump. The child is admitted to the hospital where baclofen is injected through a spinal needle. A neurologist and physical therapist evaluate the child both before and after the injection. If the drug treatment is successful, surgical pump placement is recommended.
While baclofen is very effective in reducing overall tone and spasticity, the tone reduction is not specific. All muscles will have reduced tone. When a child's muscles are so stiff that the child is difficult to position and care for, the baclofen pump is very useful. It may also be beneficial in improving the child's upper extremity function by increasing the child's range of independent motion.
BOTOX® Injection Therapy
contributed by Edward M. Goldstein, M.D.
BOTOX® is a purified form of botulinum toxin, a toxin found in contaminated food. When ingested, the toxin produces a condition called botulism, characterized by profound muscle weakness. This toxin is effective in the treatment of spasticity when used very selectively. Spastic muscles are selectively weakened through the injection of small amounts of the toxin. BOTOX® can be used in any muscle group but is most effective in smaller muscles such as those controlling the wrist.
After evaluation of the potential risks and benefits by the Children's Healthcare of Atlanta spasticity team, suitable candidates are sedated and the injections are administered to precise points. The neurologist uses needles connected to an electromyograph to target selected muscles. Precision in injection placement enhances the effectiveness of the procedure. The muscles are usually weak within two to three days and the effect lasts two to six months.
BOTOX® is most effective in treating focused areas of spasticity. Generalized spasticity in the lower limbs is difficult to treat with injections because so many injections would be required.
Orthopaedic Management of Spasticity
contributed by Michael Schmitz, M.D.
For some children with spasticity, surgery performed on the bones, joints, muscles and tendons limits the harmful effects of spasticity and maximizes function. Biomechanics dictate that a lengthened muscle tendon unit is weaker than a normal muscle tendon unit. Orthopaedic surgeons at Children’s Healthcare of Atlanta are able to selectively lengthen tight, spastic muscles to balance their strength with normal muscles. This produces a smoother gait and limits the harmful effects of spasticity, primarily joint deformity in both the soft tissues (tendons, ligaments, muscle) and bone. At times, orthopaedic surgery may be required to treat fixed deformity in the hips, knees or ankles.
Orthopaedic surgery is particularly effective when fixed deformity exists in the limbs, and is effective in weakening muscles regardless of their size and strength. Post-operatively, casting is often used to maintain the benefits of surgery while the bone and soft tissue heals.
In addition to muscle lengthening surgery, orthopaedic management of spasticity includes:
- joint contracture release: where the goal is to allow greater range of motion
- spinal fusions: where the goal is upright functional posture in children with poor trunk control related to muscle tightness
- femoral or pelvic osteotomy: where the goal is to keep the hip joint intact in children whose muscle contractures pull the hip bone out of the hip socket
- seating and other mobility devices: where the goal is to enable children to be as mobile and functional as possible
- orthotics and bracing: where the goal is to maintain proper positioning of a joint