Spasticity Management and Contractures

Spasticity of muscles not only causes functional impairments but also is associated with the development of bony deformity in many children with cerebral palsy. Management occurs in progressive stages depending on the functional impairments. Physiotherapy, orthotics, medications, and then surgeries are used. When left untreated, the child is likely to develop contractures and positional deformities.

Oral medications have been used to treat spasticity in recent years, including benzodiazepines, dantrolene, and baclofen. Their use has been limited by the development of tolerance for dosages, narrow therapeutic ranges, hepatic toxicity, and sedation. Injections of alcohol in the form of nerve-point blocks and botulinium toxin into the muscle also have been used. These treatments are more invasive, can be painful, are of limited duration (3-6 months), and can result in loss of function for a short period of time. They also can be very effective in decreasing spasticity and improving the child's function.

Surgical treatment of spasticity comes from two different directions at this time. Orthopedic surgeons operate to correct skeletal deformities, release contractures, and rebalance muscles to improve function. Tendon lengthening, tendon releases, muscle transfers, and osteotomies are the primary procedures. Neurosurgeons operate to reduce spasticity and prevent bony deformities and functional losses.5 Neurosurgical procedures include baclofen pumps that can dispense medication directly into the intrathecal sac to eliminate systemic side effects seen in oral medications and selective dorsal rhizotomies that provide a permanent reduction in tone.

The emergency physician may be called on to evaluate pain or loss of function and should be aware of these procedures and medications and their effects. Following injection procedures, there are occasionally muscle imbalances with muscle spasms and pain. Following injection procedures and surgery, there may be loss of function in the affected extremities, and with botulinum toxin, there have been rare cases of systemic effects of short duration (personal observation). The baclofen pump, which has an 18-mL drug reservoir, can be palpated as a circular metal disk in the abdominal wall. In the event of pump failure, there could be a drug overdose. Symptoms of baclofen overdose include drowsiness, light-headedness, dizziness, somnolence, respiratory depression, seizures, rostral progression of hypotonia, and loss of consciousness progressing to coma. See Fig 13,4.-1. and Fig 134:2 for management of baclofen overdose.

Baclofen Overdose
FIG. 134-1. Management of intrathecal baclofen overdose.
Intrathecal Baclofen Toxicity

Contractures of the extremities are one of the most commonly perceived difficulties of children with cerebral palsy. When spasticity is not treated, major problems can develop at the hip, ankle, wrist, and hand. In a small number of cases, elbow, shoulder girdle, and knee deformities are of concern. Adductor contractures of the hips may interfere with perineal hygiene and sitting. Hip flexion contractures may interfere with standing and independent transfers. Hip subluxation and dislocation may interfere with ambulation and may result in chronic pain syndromes and arthritis when the child becomes an adult. 67 The routine treatment for the pain is the same as for degenerative arthritis. Bracing is used for management of contractures and should be closely evaluated when wounds are sustained in braced areas. Bracing will hold the joint in a different position, and areas of skin tension will change with bracing. Placement of sutures or dressings may be affected by the brace or the altered position of an extremity without a brace. Friction from the brace could impair wound healing, increase the chance of infection, and create new wounds due to the pressure of the brace if proper assessment and attention to the brace is not part of the management. Removal of a brace may be required in early wound management unless a tension problem will complicate management more. Similar problems may occur with serial casting procedures.

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