This guideline is really aimed at the ‘Network Teams’ (ie multidisciplinary) involved in caring for these children. There were a few things that I was not aware of. Though they won’t alter our practice much, it may give a better appreciation of the treatments patients may be having. The drug treatments and ‘Hip Migration’ are worth reading if nothing else.
Consequences of spasticity:
- Impaired motor function
- Delayed motor development
- Spasms are often painful
- The contractures and spasms can make care difficult
Contractures are caused by muscle shortening, but this can be exacerbated by immobility or scarring, which is why treatment of spasticity is so important. Treatments include stretches (both active and passive), constraint induced movement therapy (where the ‘good’ limb is immobilised to encourage use of the ‘bad’ limb), orthoses, drugs and surgery.
Orthoses. I always thought that orthoses were mainly supportive, but they have much broader roles. They can prevent or slow contractures and hip migration (see below). They can relieve discomfort and they can protect vulnerable skin areas.
Drug Treatment. Baclofen is used for long term treatment of spasticity, but diazepam can be used for short term relief in crises or when a fast action is required. Both baclofen and diazepam need to be tapered off when their use is stopped or reduced. Other treatments include Botulinum A and Intrathecal baclofen (through a pump placed in the abdomen) .
Hip Migration. This is an important consequence to be aware of. Contractures can pull the femoral head up. Children with bilateral spasticity are at higher risk. If there is hip pain, leg length discrepancy, increased muscle tone around the joint or worsening of movement, then get an xray. If there is over 30% migration, they will need an orthopaedic opinion.
Surgery. As well as hip migration, surgery may be needed for spinal problems, eg kyphosis. They can also do a ‘selective dorsal rhizotomy’ where sensory nerves are cut to reduce spasticity. The long term effects of this are still uncertain.