Recent developments in therapeutic interventions for children with spasticity have complicated managerial decision making. A simplified paradigm for the pathophysiology of spasticity is presented, which emphasizes the ways in which treatment modalities disrupt hyperexcitable segmental spinal reflex arcs. Various techniques for the management of spasticity are reviewed, along with factors relevant to proper patient selection for therapeutic intervention. Potential goals for spasticity management are considered as are outcome measures for assessing the efficacy of these technologies. (J Child Neurol 2001;16:16-23).
Get full access to this article
View all access options for this article.
References
1.
Trimble MH, Du P., Brunt D., Thompson FJ: Modulation of triceps surae H-reflexes as a function of the reflex activation history during standing and stepping. Brain Res2000;858:274-283.
2.
Mayer NH: Clinicophysiologic concepts of spasticity and motor dysfunction in adults with an upper motoneuron lesion. Muscle Nerve1997;6(Suppl):S1-S13.
3.
Gans BM, Glenn MB: Introduction, in Glenn MB, Whyte J (eds): The Practical Management of Spasticity in Children and Adults. Philadelphia, Lea & Febiger, 1990, 1-7.
4.
Brunstrom JE: Cerebral palsy, in Maria BL (ed): Current Management in Child Neurology. Hamilton, ON, BC Decker, 1999, 163-168.
5.
Palmer FB, Shapiro BK, Wachtel RC, et al: The effects of physical therapy on cerebral palsy. N Engl J Med1988;318:803-808.
6.
Leach J.: Children undergoing treatment with botulinum toxin: The role of the physical therapist. Muscle Nerve1997;6(Suppl): S194-S207.
7.
Gracies JM, Nance P., Elovic E., et al: Traditional pharmacological treatments for spasticity Part II: General and regional treatments. Muscle Nerve1997;6(Suppl):S92-S120.
8.
Nance PW, Young RR: Antispasticity medications. Phys Med Rehabil Clin North Am1999;10:337-355.
9.
On AY, Kirazli Y., Kismali B.: Mechanisms of action of phenol block and botulinus toxin type A in relieving spasticity: Electrophysiologic investigation and follow-up. Am JPhys Med Rehabil1999;78: 344-349.
10.
Gracies JM, Elovic E., McGuire J., Simpson D.: Traditional pharmacological treatments for spasticity Part I: Local treatments . Muscle Nerve1997;6(Suppl):S61-S91.
11.
On AY, Kirazli Y., Kismali B., Aksit R.: Comparison of phenol block and botulinum toxin type A in the treatment of spastic foot after stroke: A randomized, double-blind trial. Am J Phys Med Rehabil1998;77:510-515.
12.
Glenn MB: Nerve blocks, in Glenn MB, Whyte J (eds): The Practical Management of Spasticity in Children and Adults. Philadelphia, Lea & Febiger, 1990, 227-258.
Russman BS, Tilton A., Gormley ME: Cerebral palsy: A rational approach to a treatment protocol, and the role of botulinum toxin in treatment. Muscle Nerve1997;6(Suppl):S181-S193.
15.
Molenaers G. , Desloovere K., Eyssen M., et al: Botulinum toxin type A treatment of cerebral palsy: An integrated approach. Eur Neurol1999;6(Suppl):S51-S57.
16.
Koman LA, Mooney JF, Smith BP, et al: Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: A randomized, double-blind, placebo-controlled trial. J Pediatr Orthop2000;20:108-115.
17.
Wong V.: Use of botulinum toxin injection in 17 children with spastic cerebral palsy . Pediatr Neurol1998;18:124-131.
18.
Wissel J., Heinen F., Schenkel A., et al: Botulinum toxin A in the management of spastic gait disorders in children and young adults with cerebral palsy: A randomized, double-blind study of "high-dose" versus "low-dose" treatment. Neuropediatrics1999;30:120-124.
19.
Friedman A. , Diamond M., Johnston MV, Daffner C.: Effects of botulinum toxin A on upper limb spasticity in children with cerebral palsy. Am J Phys Med Rehabil2000;79:53-59.
20.
Sutherland DH, Kaufman KR, Wyatt MP, et al: Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy . Gait Posture1999;10:1-9.
21.
Simpson DM: Clinical trials of botulinum toxin in the treatment of spasticity. Muscle Nerve1997;6(Suppl):S169-S175.
22.
Clinical use of botulinum toxin. Reprinted from NIH Consens Dev Conf Consens Statement Nov 12-14 1990;8(8).
23.
Lew MF, Adornato BT, Duane DD, et al: Botulinum toxin type B: A double-blind, placebo-controlled, safety and efficacy study in cervical dystonia. Neurology1997;49:701-707.
24.
Brin MF, Lew FM, Adler CH, et al: Safety and efficacy of NeuroBloc (botulinum toxin type B) in type A-resistant cervical dystoniaNeurology1999;53:1431-1438.
25.
Dabney KW, Glenn EL, Miller F.: Cerebral palsy. Curr Opin Pediatr1997;9:81-88.
26.
Renshaw TS, Green NE, Griffin PP, Root L.: Cerebral palsy: Orthopaedic management. J Bone Joint Surg Am1995;77A: 1590-1606.
27.
Steinbok P. , Schrag C.: Complications after selective posterior rhizotomy for spasticity in children with cerebral palsy. Pediatr Neurosurg1998;28:300-313.
28.
Peacock WJ, Staudt LA, Nuwer MR: A neurosurgical approach to spasticity: Selective posterior rhizotomy, in Wilkins RW, Rengachary SS (eds): Neurosurgery Update II: Vascular, Spinal, Pediatric and Functional Neurosurgery. New York, McGraw Hill, 1991, 403-407.
29.
Chicoine MR , Park TS, Vogler GP, Kaufman BA: Predictors of ability to walk after selective dorsal rhizotomy in children with cerebral palsy. Neurosurgery1996;38:711-714.
30.
Subramanian N., Vaughan CL, Peter JC, Arens LJ: Gait before and 10 years after rhizotomy in children with cerebral palsy spasticity. J Neurosurg1998;88:1014-1019.
31.
Nishida F., Thatcher SW, Marty GR: Selective posterior rhizotomy for children with cerebral palsy: A 7-year experience . Childs Nerv Syst1995;11:374-380.
32.
Engsberg JR , Ross SA, Park TS: Changes in ankle spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy. J Neurosurg1999;91:727-732.
33.
Steinbok P. , Reiner AM, Beauchamp R., et al: A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol1997;39:178-184.
34.
Thomas SS, Aiona MD, Pierce R., Piatt JH: Gait changes in children with spastic diplegia after selective dorsal rhizotomy . J Pediatr Orthop1996;16:747-752.
35.
Chicoine MR , Park TS, Kaufman BA: Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy. J Neurosurg1997;86:34-39.
36.
Carroll KL, Moore KR, Stevens PM: Orthopedic procedures after rhizotomy. J Pediatr Orthop1998;18:69-74.
37.
Albright AL , Barry MJ, Fasick MP, Janosky J.: Effects of continuous intrathecal baclofen infusion and selective posterior rhizotomy on upper extremity spasticity. Pediatr Neurosurg1995;23:82-85.
38.
Albright AL : Baclofen in the treatment of cerebral palsy . J Child Neurol1996;11:77-83.
39.
Gilmartin R. , Bruce D., Storrs BB, et al: Intrathecal baclofen for management of spastic cerebral palsy: Multicenter trial. J Child Neurol2000;15:71-77.
40.
Müller-Schwere G., Penn RD: Physostigmine in the treatment of intrathecal baclofen overdose. J Neurosurg1989;71:273-275.
41.
Armstrong RW , Steinbok P., Cochrane DD, et al: Intrathecally administered baclofen for treatment of children with spasticity of cerebral origin. J Neurosurg1997;87:409-414.
42.
Meythaler JM , McCary A., Hadley MN: Prospective assessment of continuous intrathecal infusion of baclofen for spasticity caused by acquired brain injury: A preliminary report. JNeurosurg1997; 87:415-419.
43.
Rawicki B.: Treatment of cerebral origin spasticity with continuous intrathecal baclofen delivered via an implantable pump: Long-term follow-up review of 18 patients . J Neurosurg1999;91:733-736.
44.
Campbell SK , Almeida GL, Penn RD, Corcos DM: The effects of intrathecally administered baclofen on function in patients with spasticity. Phys Ther1995;75:352-362.
45.
Gerszten PC , Albright AL, Johnstone GF: Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy. J Neurosurg1998;88:1009-1013.
46.
Gormley ME, O'Brian CF, Yablon SA: A clinical overview of treatment decisions in the management of spasticity . Muscle Nerve1997; 6(Suppl):S14-S20.
47.
Rattery TE, Leahey L., Hyndman J., et al: Recurrence after Achilles tendon lengthening in cerebral palsy . J Pediatr Orthop1993;13: 184-187.
48.
Sussman MD, ed: The Diplegic Child: Evaluation and Management. Rosemont, IL: American Academy of Orthopedic Surgeons, 1992.
49.
Green LB, Nelson VS: Death after acute withdrawal of intrathecal baclofen: Case report and literature review. Arch Phys Med Rehabil1999;80:1600-1604.
50.
Pierson SH: Outcome measures in spasticity management. Muscle Nerve1997;6(Suppl):S36-S48.
51.
Ketelaar M. , Vermeer A., Helders PJ: Functional motor abilities of children with cerebral palsy: A systematic literature review of assessment measures. Clin Rehabil1998; 12:369-380.
52.
Rissell DJ, Rosenbaum PL, Growland C., et al: Manual for the Gross Motor Function Measure. Hamilton, ON, McMaster University, 1993.
53.
Haley SM, Coster WJ, Ludlow LH, et al: Pediatric Evaluation of Disability Inventory (PEDI). Boston, New England Medical Center Hospitals, 1992.
