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Title: ITB Therapy: Role of the Interdisciplinary Team

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Title: ITB Therapy: Role of the Interdisciplinary Team

1
Patient Management
2
Program Objectives

Define spasticity related anatomy and current
understanding of the pathophysiology of
spasticity and other movement disorders.
Describe the benefits and detriments of
spasticity and how they relate to goal setting.
Describe patient examination and evaluation
including the use of appropriate outcome
measures and related rehab interventions.
List the indications risks and benefits of
current treatment options.
Discuss the role of the interdisciplinary team in
the assessment and treatment of spasticity.

3
Spasticity (Lance 1980)

Motor disorder
Velocity dependent increase in tonic stretch
reflexes
Hyperexcitability of the stretch reflex
Exaggerated tendon jerks
One component of the upper motor neuron syndrome
Altered activity patterns of motor units
occurring in response to sensory and central
command signals which lead to co-contractions
mass movements and abnormal postural control
(Wiesendanger 1991)

4
Upper Motor Neuron Syndrome (UMNS)

Positive Signs
Spasticity
Rigidity
Hyperreflexia
Primitive reflexes
Clonus

Negative Signs
Lack of strength
Lack of motor control
Lack of coordination

(Young 1989 Young 1997)
5
Pathophysiology of Spasticity

Proposed Theories
1. Imbalance between excitatory and inhibitory
impulses to the alpha motor neuron
--Due to lack of descending inhibitory input to
the alpha motor neuron

6
Pathophysiology of Spasticity

2. Descending pathways also influence Renshaw
cells (neurons located in ventral horn) which
suppress repeated firing of alpha motor neurons
--lesion decreases activity of Renshaw cells
reduce their inhibitory activity
--this results in rapid repeated firing of
alpha
motor neurons from repetitive stretch
reflexes
triggered by voluntary or passive stretch of
muscle.

7
Pathophysiology of Spasticity

Descending pathways also inhibit Golgi
Tendon Organ (GTO)
--lesion results in lack of inhibition of GTO
excitation of stretch reflex

8
Range of Muscle Tone
Normal Range ofMuscle Tone
Flaccidity
Hypotonia
Rigidity
Hypertonia
9
Involuntary Movement Disorders

Dystonia Abnormal posturing twisting or
repetitive movements
Chorea Irregular dance-like movements
Athetosis Writhing distal movements
Choreoathetosis Combination of both chorea and
athetosis
Ataxia Flailing movements wide-based gait

10
Contracture

The difference between the joint angle at which
extreme resistance to passive movement occurs and
normal end-range of motion.

(Olney Wright 1994)
11
Contracture

Spasticity involves increased muscle activity
from the agonist muscle group that is not
balanced by its antagonist
Results in persistent abnormal joint positions
Other factors that influence joint mobility
Musculoskeletal growth in CP
Arthritis (osteo and rheumatoid)
Previous injuries to joints or soft tissue
Previous orthopedic surgeries
Heterotopic ossification

12
Possible Advantages of Spasticity

Maintains muscle bulk
Helps support circulatory function
May prevent formation of deep vein thrombosis
May assist in activities of daily living
May assist with postural control

13
Consequences of Spasticity

May interfere with mobility exercise joint
range of motion
May interfere with activities of daily living
May cause pain and sleep disturbances
Can make patient care more difficult

14
Considerations

Spasticity waxes and wanes
Dynamic vs static tone
Multiple muscle groups may contribute to joint
deformity
Patient perception

15
Clinical Challenge

Spasticity is more difficult to characterize
than to recognize and STILL MORE difficult to
quantify.
(Katz Rymer 1989)

16
The Therapist Role in Spasticity Management

Identify evaluate and educate the patient
Guide the patient in setting goals
Provide rehabilitation interventions that
Decrease the influence of the positive signs
Improve the negative signs
Facilitate newer rehabilitation techniques
Provide feedback and consultation to rest of
spasticity-management team

17
Treatment Options for Patients with Spasticity
Patient
IntrathecalBaclofen (ITB) Therapy
Oral Medications
Rehabilitation Therapy
Orthopedic Surgery
Injection Therapy
Neurosurgery
18
Oral Medications

Most common
Baclofen (Lioresal)
Diazepam (Valium)
Tizanidine (Zanaflex)
Dantrolene sodium (Dantrium)

19
Site of Action for Oral Medications

Drug
Baclofen
Diazepam
Tizanidine
Dantrolene sodium

Site of action
Central Nervous System
Central Nervous System
Central Nervous System
Peripheral muscle

20
Oral Medications Considerations

Decrease positive signs
Spasticity Dystonia (multi-segmental)
Spasms
Improve negative signs
Lack of Motor Control (use rehab to address)
Consider other negative signs
Lack of Strength (consider whether decreasing
hypertonia would be detrimental to posture and
function)

21
Oral Medications

Advantages
Non-invasive not permanent
Effective management for some patients
Disadvantages
Difficult to achieve a steady state
Following a schedule may be difficult
Side effects drowsiness hypotonia and weakness
may limit effectiveness

22
Injection Therapy

Anesthetic / Diagnostic Nerve Blocks
Procaine
Lidocaine
Neurolytic Nerve Blocks
Ethanol
Phenol
Botulinum Toxin

23
Botulinum Toxin

Clostridium botulinum injected into the muscle
Interferes with release of acetylcholine at the
neuromuscular junction
No systemic effect
May be administered without anesthesia
EMG guidance for small muscles
Results typically last 3-6 months

24
NMJ
Purves D Augustine GJ Fitzpatrick D Katz LC
LaMantia A-S McNamara JO Williams SM
Neuroscience. Sunderland MA Sinauer Associates.
2001 Pg. 113-114
25
NMJ Proteins
Purves D Augustine GJ Fitzpatrick D Katz LC
LaMantia A-S McNamara JO Williams SM
Neuroscience. Sunderland MA Sinauer Associates.
2001 Pg. 113-114
26
Botox Effect on NMJ
Purves D Augustine GJ Fitzpatrick D Katz LC
LaMantia A-S McNamara JO Williams SM
Neuroscience. Sunderland MA Sinauer Associates.
2001 Pg. 113-114
27
Injection Therapy Considerations

Decrease positive signs
Focal spasticity or dystonia
Contracture
Improve negative signs
Lack of Motor Control (use rehab to address)
Lack of Strength (use rehab to address)
opportunity to work on strength and better
alignment
Consider other negative signs
Lack of Strength (consider whether decreasing
hypertonia would be detrimental to posture and
function)

28
Injections

Advantages
Not permanent
Evidence to support efficacy in reducing
spasticity and improving function
Effects are localized - not systemic
Disadvantages
Not permanent - may need to repeat injections
Ethanol and Phenol require greater skill to
inject increased risk of paresthesias
dysesthesias
Botulinum toxin more expensive than other
injections may develop antibodies

29
Why Botox Wears Off

Sprouting

Courtesy of Medtronic ITB
30
Intrathecal Baclofen (ITB) Therapy

Courtesy of Medtronic ITB

31
Intrathecal Delivery of Baclofen

Acts as GABAb receptor agonist
GABA (gamma-amino butyric acid) is an inhibitory
CNS neurotransmitter
Two receptor types (GABAa and GABAb)
Mechanism of action is probably presynaptic
inhibition
Inhibits release of calcium into presynaptic
terminals
Thereby impedes release of excitatory
neurotransmitters
Baclofen is delivered directly into CSF in
intrathecal space

32
Why Intrathecal vs. Oral

Intrathecal
Lower doses than those required with oral
administration
Potentially fewer systemic side effects
Oral
Low blood/brain barrier penetration with high
systemic absorption and low CNS absorption
Lack of preferential spinal cord distribution
Adverse effects such as drowsiness for some
patients

33
Pharmacokinetics of Baclofen

Intrathecal
600 mcg/day dose 1.24 mcg/mL IT lumbar
concentration
Lumbar to cervical concentration is 41 with
lumbar catheter tip placement
Therapeutic dose is 1/100 of oral
Oral
60 mg dose 0.024 mcg/mL IT lumbar concentration
Half-life 3-4 hours

(Knutsson et al 1974 Kroin Penn 1991)
34
SynchroMed Infusion System Components

Pump
infuses drug at programmed rate
Catheter
delivers drug to theintrathecal (subarachnoid)
space of the spinal cord
Programmer
allows for precise dosing
easily adjustable dosing

Courtesy of Medtronic SynchroMed EL Infusion
System
35
Indications for ITB Therapy

Patients must demonstrate a positive response to
the screening test
Patients with spasticity of spinal origin
unresponsive to oral antispasmodics
and/or experience unacceptable side effects at
effective doses of oral baclofen
Patients with spasticity of cerebral origin must
be one year post brain injury to be considered
for ITB Therapy

36
ITB Therapy Process

Stage 1 Patient Selection
Stage 2 Screening Test
Stage 3 Implant
Stage 4 Maintenance Follow-up Rehab

37
Screening Test Flow Chart
Bolus 50 mcg
-

24 hrs after Bolus 75 mcg
-

24 hrs after Bolus 100 mcg

Positive Response Implant Negative
Response No Implant
-
-

Not a Candidate
Intrathecal Baclofen Therapy Clinical Reference
Guide for Spasticity Management Medtronic Inc.
38
Therapy Examination During the Screening Test

Typically assess at 2 and 4 hours post bolus
Ashworth or Modified Ashworth Scales(AS or MAS)
Passive/Active Range of Motion(PROM / AROM)
Observe movement patterns
Spasm Scale
Pain Scale

39
Therapist Role Post-Implant

Determine appropriate therapy venue
Propose treatment plan
Provide input regarding dosing

40
Potential Risks of ITB Therapy

Common side effects
Hypotonia
Somnolence
Nausea/vomiting
Headache
Dizziness
Paresthesias
Catheter and procedural complications may occur
Overdose (rare)
Withdrawal

41
Baclofen Overdose

Symptoms
Drowsiness
Lightheadedness
Dizziness
Somnolence
Respiratory depression
Seizures
Rostral progression of hypotonia
Loss of consciousness (possible progression to
coma)
Take patient to emergency department!

42
Baclofen Withdrawal

Symptoms
Increased spasticity
Itching without rash
Tingling paresthesias skin crawling
Hyperthermia
Headache
Hypotension
Seizures
Hallucinations
Altered mental status
Autonomic dysreflexia medical emergency

43
ITB Therapy Considerations

Decrease positive signs during screening test
Spasticity

Improve negative signs
Lack of Motor Control (use rehab to address)
Consider other negative signs
Lack of Strength (consider whether decreasing
hypertonia would be detrimental to posture and
function)

44
ITB Therapy Considerations

Positive signs - ITB Therapy will not change
these signs
Intrinsic muscle properties
Contracture
Negative signs - will need rehab to see changes
Lack of Strength
Lack of Balance

45
Efficacy of ITB Therapy inAdults and Children

Positive responses to screening trials
86 cerebral origin
97 spinal cord origin
Upper and lower extremity effects noted
Improvements for patients with functional goals
for patients with goals of improving comfort and
ease of care

(Albright et al 1991 Albright et al 1995 Penn
et al 1989 Medtronic data on file)
46
ITB Therapy

Advantages
Reversible
Non-invasive dose adjustments
Potential for fewer side effects than oral drugs
Evidence to support efficacy in reducing
spasticity
May improve function comfort and care
Disadvantages
Complications infection catheter problems
overdose baclofen withdrawal
Refills approximately every 3 months
Cost

47
Neurosurgical Treatments

Neurectomy
Myelotomy
Anterior Rhizotomy
Selective Dorsal Rhizotomy
Cordectomy
Thalamotomy

(Simpson 1995)
48
Selective Dorsal Rhizotomy (SDR)

Dorsal sensory nerve roots are severed
Each rootlet within root is stimulated
Abnormally-responding rootlets are severed
Often performed on children between ages of 7 and
10 years
Usually involves 6-12 months of intensive therapy
post-operatively if improved function is goal
Complications include possible sensory loss

(Abbott et al 1993 Van de Wiele et al 1996)
49
Selective Dorsal Rhizotomy (SDR)

Antonio R. Prats M.D. F.A.C.S. Miami Florida

50
SDR Considerations

Decrease positive signs
Spasticity (multi-segmental)
Improve negative signs
Lack of Motor Control (use rehab to address)
Consider other negative signs
Lack of Strength (consider whether decreasing
hypertonia will be detrimental to posture and
function)

(McLaughlin et al 1998 Steinbok et al 1997
Wright et al 1998)
51
SDR

Advantages
Permanent one-time procedure
Evidence for efficacy in reducing spasticity and
improving function in children with spastic
diplegia
Disadvantages
Permanent may need spasticity
Potential adverse effects spinal sensory
Not effective for dystonia

52
Orthopedic Surgery

Soft-tissue operations
lengthenings
releases
tendon transfers
Bony operations
osteotomies
fusions

53
Orthopedic Surgery Considerations

Decrease positive signs
Contracture
Abnormal Bony Alignment
Improve negative signs
Lack of Motor Control (may improve with rehab)
Lack of Strength (may improve with better
biomechanical alignment may require rehab)
Lack of Balance (may improve if better base of
support)

54
Orthopedic Surgery

Advantages
Effects usually last a few years
Disadvantages
Anesthesia risks
Non-weightbearing after bony procedures
Risk of weakness decreased function

55
Interdisciplinary ApproachTreatment Team Members
56
Rehabilitation

Advantages
Noninvasive
Active involvement of the patient and/or family
Emphasis on functional gains
Disadvantages
Casting orthoses positioning skin integrity
at risk
Cost of treatments equipment
Requires patient motivation participation for
functional gains motor learning

57
Elements of Patient Management for Optimal
Outcomes

Guide to Physical Therapist Practice

58
Elements of Patient Management
Diagnosis
Evaluation
Prognosis
Outcomes
Examination
Intervention
59
Patient Examination

Patient history
Psychsocial factors
Tests and measures

60
Patient History

Focal or generalized tone
Evolution of spasticity
History of intervention
Past medical history
Comorbidities
Chief complaint
Patients/caregiver level of understanding

61
Psychosocial Factors

Coping strategies/parenting styles
Learning styles
Cognition
Family/community support
Funding sources

62
Tests and Measures

Muscle Performance
Range of Motion
Integumentary Integrity
Pain
Orthotic Protective and Supportive Devices
Fatigue/Cardiovascular Endurance
Posture
Reflex Integrity
Neuromotor Development and Sensory Integration
Self-care and Home Management

63
Tests and Measuresfor Muscle Performance

Static and dynamic muscle tone
Muscle strength and selective motor control
Function

64
Static Muscle Tone

Ashworth and Modified Ashworth scale
Tardieu scale
Spasm Frequency scale
EMG/ H Reflex

65
Modified Ashworth Scale
(Bohannon Smith 1987)
66
Modified Tardieu Scale (Boyd 1999)

Consistent velocity stretch of muscle
Standard positions for specific muscles
Note point of resistance to maximal velocity
stretch (R1)
Note amount of muscle contracture or muscle
length (R2)
Relationship between R2-R1

67
Spasm ScaleSpasm Frequency
Penn Savoy New England Journal of Medicine
1989 3201517-1521.
68
Dynamic Muscle Tone

Observation of Movement Patterns
Equinus gait
Scissor gait
Upper extremity flexion/adduction
Mass movement postures
Observation Tips
Try observing with and without orthoses or
ambulation aids
Video taping can be very helpful

69
Additional Examination Considerations

Assistive devices utilized
Seating system
Positioning
Functional tasks
Status of oral medications

70
Typical Upper Extremity

Shoulder internal rotation
Elbow flexion
Forearm pronation
Wrist/ Fingers flexion
Thumb in palm

71
Typical Lower Extremity Postures

Hip Knee Extended
Ankle Plantarflexed
Foot/ ankle inverted
OR
Hip Knee flexed
Ankle Plantarflexed

72
Consider the Positive Signs

Is there
Moderate to severe spasticity
Static or dynamic spasticity
Generalized or focal spasticity
What are the effects on
Function
Comfort
Care
Safety
Is intervention directed at these signs warranted

73
Possible Advantages of Spasticity

Maintains muscle bulk and tone
Helps support circulatory function
May assist in transfers and ambulation
May assist in activities of daily living

74
Consider the Negative Signs

Is there a lack of
Strength
Motor control
Coordination
Balance and posture
Endurance
What are the effects on
Function
Comfort
Care
Safety
Is intervention directed at these signs warranted

75
Consequences of Spasticity

May interfere with
ADLs dressing and hygiene
Mobility rolling sit supine transfers
ambulation
Exercise
Joint range of motion
Coordination of movement
Ability to move effort
Tolerance of orthotics/ splints
Skin integrity
Ability to sleep/ rest
Feeding and speech
Patient Care
Driving

76
Clinical Evaluation and Patients Perspective

Most importantly
Does spasticity interfere with function care
or comfort

77
Is Spasticity a ProblemGoals of Spasticity
Management

Decrease spasticity
Improve functional ability and independence
Decrease pain associated with spasticity
Prevent/ limit contractures
Improve mobility/ ambulation
Facilitate ADLs/ hygiene
Save caregiver time effort

78
Gait Assessment

Foot clearance with swing
Foot position at late swing
Step length
Leg position in stance
Amount of effort required to ambulate

79
Abnormal Gait in Spastic Diplegia

Gait is delayed and requires great effort
Adducted with IR of Hip
Increased knee flexion
Forefoot strike
Early heel rise
Excessive lumbar lordosis
Circumducts or excessively flexes hip-knee to
advance leg

80
Abnormal Gait with Spastic Hemiplegia

Toe strike
Knee hyperextension
Posturing of ipsilateral upper extremity
Trunk lean

81
Abnormal Gait with Spastic Hemiplegia

To advance LE
Hip hiking
Trunk lean to opposite side
Circumduction
Excessive Hip Knee Flexion
Vaulting

82
Abnormal Gait with Spastic Hemiplegia
83
Functional PrognosisPrimarily Ambulatory

Balance and safety
Endurance and energy conservation
Gait pattern
Additional areas where skill level could improve
Driving
Athletic performance

84
Functional PrognosisPrimarily Wheelchair Use

Transfers mobility and safety
Position and function in wheelchair
Additional goals could include
Fine motor control switch access
Speech
Feeding oral motor skills
Preparation for other interventions

85
Rehabilitation Therapy

EMG biofeedback
Electrical stimulation
Vibration of the antagonist
Constraint-induced
Movement Therapy
Selective Strengthening of Antagonist
Aquatic Therapy
Handling/ Inhibitory Pressure

Stretching
Casting
Orthoses
Weight bearing
Positioning Seating
-Podus Boots
-Versaform
-Splints/ Bivalves
-Aircast
Practice functional tasks
Sensory Integration

86
Focus on.

Elongation of shortened tissues
Strengthening
Improving motor control
Address underlying weakness

87
Treatment Approaches

NDT
Normalize muscle tone/ posture
Inhibit reflexes
Facilitate normal movement
Use of handling/ facilitation techniques
Motor Learning
Practice functional tasks

88
Treatment Approaches

Therapeutic Exercise
Stretching and ROM
Active assistive active resistive exercise
E-stim. (fatigue OR strengthen)
Weight bearing
Aquatic therapy
Rhythmic rotation
Contract-Relax
Handling/ key points of control Inhibitory
pressure
Ice
Warmth
Biofeedback

89
Treatment Approaches

Functional Training
gait ADLs mobility school-based (to enhance
education)
Consider equipment and environmental adaptations
to maximize function

90
Other Treatment Approaches

Restraint-induced
Play
FES
School based vs. medically based
Not just one approachblending of whats
effective for
patient

91
Positioning

Positioning (in bed w/c and other)
Podus boots
Versaform
Splints
Aircast

92
Positioning
93
Casting/ Splinting

Inhibitory Casting
Serial Casting
Bivalve Splints
AFOs
SMOs
Upper Extremity/ Hand Splints

94
Inhibitory Casting

Theoretical Principles
Static positioning interrupts stretch reflex
Circumferential casting provides neutral warmth
and constant pressure
Decreases variability of cutaneous sensory input
which can elicit stretch reflex
Promotes changes in muscle tendon length and
sarcomere distribution

95
Inhibitory Casting

Indications
Elevated muscle tone present
Full/ functional ROM present
Little isolated active (non-synergistic)
movement is present
Holding or posturing is observed

96
Inhibitory Casting

General Principles
Cast in sub-maximal range
Leave on 3-5 days
Complete a thorough assessment after removal
Apply new cast or bivalve ASAP
Use with abnormal movement

97
Serial Casting

Theoretical Principles
Low-force long-duration stretch produces
residual elongation of connective tissue
Gentle prolonged stretch results in cell
division
Provides inhibitory effect

98
Serial Casting

Indications
Spasticity is present
Loss of PROM is significant

99
Serial Casting

General Principles
Apply cast in submaximal range
Leave on 5-10 days
Complete thorough assessment after removal
Casting multiple joints
Decide what to do next (cast or splint)
If cast again do immediately
If splinting do ASAP

100
Therapist Evaluation Prior to Casting

Cognitive status
Sensation
Skin integrity
Effects of positioning and gravity
Psychosocial issues
Recommendation for other interventions (botox)
Type of casting serial vs. inhibitory
Quality of motion
Active vs. passive
Isolated vs. synergistic
Do ALL prior to casting and again AFTER each cast

101
Contraindications for Casting

Medically unstable
Edematous areas
Fragile skin
Compromised circulation
Agitation and confusion
Impaired Sensation
Open Wounds
Abrasions
Lacerations

102
Contraindications for Casting

Multiple Extremities
Multiple Joints
Bony Malformations
Subluxation
Unhealed fracture
HO
Loose bodies
Arthritis

103
Cast Padding

Progressive Casting and Splinting for Lower
Extremity Deformities on Children with Neuromotor
Dysfunction- Beverly Cusick Therapy Skill
Builders Tuscon AR 1990 pg. 278

104
Caregiver Monitors

Pulse and respirations
Skin temp
Skin color
Pain
Edema
Reddened areas or blisters
Cast condition
Limb position

105
General Info on Casting

Casting is usually most effective proximal
distal will see some distal inhibition with
proximal inhibition
Need to prioritize individually per patient
needs medical status and tolerance
Heat generated in a cast may be in itself
inhibitory for tone

106
More General Info on Casting Spasticity
Management

Air splints are generally ineffective as means of
inhibiting tone due to softness and inconsistent
pressure best used for positioning during
treatment
Whole body positioning may be beneficial
primitive reflex patterns and synergies need to
be inhibited to decrease tone
Serial casting uses same principles of
Inhibitory but low load prolonged stretch
physiologic changes ( in sarcomeres) permanent
change in muscle length

107
Long Arm Cast

Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998

108
Drop-out Elbow Cast
Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998
109
Drop-out Cast

Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998

110
Hand Wrist Casts

Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998

111
Hand Wrist Casts
Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998
112
Leg Casts

Gillen G Burkhardt A Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis 1998

113
Casting

Another tool in our bag
-cost-effective vs medical
-fairly non-invasive
-it works!

114
Additional Roles of Therapists

Input for selection of muscle injection/ surgical
intervention/ medication based on functional
picture
Feedback to physician regarding effects of
medical management
Suggestions/ ideas for future management to
maximize function
Seek input of other team members
Monitor patient for changes in status
Provide inhibition facilitation techniques
especially after casting /or medical treatments
Serve as referral source in community
Assist with oral motor skills

115
Reassess Equipment Needs

Seating system
Standing equipment
Orthotics
Bathroom equipment
Assisted technology
Augmentative communication

116
Adult Outcomes General

Functional Independence Measure (FIM)
Functional Assessment Measure (FAM)
Canadian Occupational Performance Measure (COPM)
Goal Attainment Scaling (GAS)
Timed Up and Go (TUG)
Pain Scales

117
Adult Outcomes General

Barthel Index
Observational Gait Scale (OGS)
Sickness Impact Profile (SIP)
SF-36 (QOL measure)
3-Dimensional Gait Analysis (3DGA)

118
Adult Outcomes Stroke

Chedoke-McMaster Stroke Assessment (CMSA)
Berg Balance Scale (BBS)
Tinetti Balance Scale

119
Adult Outcomes MS

Multiple Sclerosis Functional Composite (MSFC)
Minimal Record of Disability for MS (MRDMS)
Modified Fatigue Impact Scale (MFIS)

120
Evidence Botox

Effective and safe to manage spasticity in
children
Love et al
Desloovere et al
Boyd and Hays
Chambers
Fragala
Graham
Houltram et al

121
Evidence Botox

and Adults
Hesse et al
Pierson et al
Yablon et al
Simpson et al
Graham and Rawicki

122
Evidence Casting

Effective in improving ROM and reducing
spasticity
Hill
Barnard et al
Nash
Mortenson and Eng
Cottalorda et al
Lehmkuhl et al
Booth et al

123
Evidence Botox vs. Casting

Houltram et al
Flett et al
Corry et al
Significant improvement in tone reduction and
gait for both groups
Botox was preferred treatment by caregivers
Botox lasted longer

124
Evidence Botox Casting

Booth et al both together caused faster results
(improved gait and ROM) as compared to just
casting
Desloovere et al Group casted AFTER Botox
improved more with 3DGA than group casted PRIOR
to Botox
Graham et al Less regression and loss of
function if casted with Botox than if surgery

125
Cases
126
Jeffrey

6 y/o CVA at birth/ CP Left Hemi
OT/PT since 1y/o 1-2X/ week
Spasticity Left upper lower extremities
Impaired Left sensation/ position sense
Gait toe walker decreased step length on right
circumduction to advance left leg
Impaired balance especially in standing
Short hamstrings poor sitting posture

127
Jeffrey

Treatment
Botox left finger and wrist flexors left
plantarflexors hamstrings
Inhibitory Casting left foot/ ankle in DF
Inhibitory Casting left hand/ wrist in neutral
Weight bearing
Hands and knees
Side-sitting
stance
Dynamic stretch to hamstrings and gastrocs
Splints worn at nighttime
Home Program long sitting while playing games
use of left hand
stretching wrist extension and ankle DF
Coordination balance activities

128
Jeffreys Outcome

Began walking with occasional heel strike/ flat
foot
Improvements with balance during gait on stairs
Began jumping (still uses R gt L)
Able to move ½ kneel stand over left leg
Hops on left leg with help
Limp (still present)
speed/ started running

129
Jeffreys Outcome

Ongoing
lack of heel strike
decreased push-off on left
stability in Quad
uses R gt L
Mild limp
Difficulty with advanced motor/ coordination
activities

130
Jeffreys Outcome

Opens hand fingers
Controlled grasp release
Can obtain neutral forearm position
strength proximally
Function uses left as assist
Ex shoe tying
Began walking with occasional heel strike/ flat
foot
Improvements with balance during gait on stairs
Began jumping (still uses R gt L)
Able to move ½ kneel stand over left leg
Hops on left leg with help
Limp (still present)
speed/ started running

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Jeffreys Outcome

Ongoing
Grip strength poor
Lacks full supination
Trunk substitution for IR and ER
lack of heel strike
decreased push-off on left
stability in Quad
uses R gt L
Mild limp
Difficulty with advanced motor/ coordination
activities

132
Sarah

21y/o TBI due to MVA
Rancho II
Significant Spasticity throughout extremities
trunk neck
Video

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Conclusion

Choose the treatment or treatments that address
the positive and negative signs interfering with
attainment of the patient and family/caregiver
goals keeping in mind the psychosocial and
medical factors.
COMMUNICATION
With other team members
With Physician

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Credits

To Edward Wright MD and LeaAnn Brittain ME OTR
who originally developed parts of this
presentation
To Giulianne Krug ME OTR for providing
information on spasticity and benefits of
casting.
To Medtronics for data and information graphics
and formatting used within this presentation.

135
References and Suggested Reading