Management of spasticity in cerebral palsied children by peripheral nerve block with phenol

Targeted Physical Therapy Combined with Spasticity Management Changes Motor Development Trajectory for a 2-Year-Old with Cerebral Palsy

Therapies for children with cerebral palsy (CP) often fail to address essential components of early rehabilitation: intensity, child initiation, and an embodied approach. Sitting Together And Reaching To Play (START-Play) addresses these issues while incorporating intensive family involvement to maximize therapeutic dosage. While START-Play was developed and tested on children aged 7–16 months with motor delays, the theoretical construct can be applied to intervention in children of broader ages and skills levels. This study quantifies the impact of a broader START-Play intervention combined with Botulinum toxin-A (BoNT-A) and phenol on the developmental trajectory of a 24 month-old child with bilateral spastic CP. In this AB +1 study, A consisted of multiple baseline assessments with the Gross Motor Function Measure-66 and the Assessment of Problem Solving in Play. The research participant demonstrated a stable baseline during A and changes in response to the combination of BoNT-A/phenol and 12 START-Play sessions during B, surpassing the minimal clinically important difference on the Gross Motor Function Measure-66. The follow-up data point (+1) was completed after a second round of BoNT-A/phenol injections. While the findings suggest the participant improved his gross motor skills with BoNT-A/phenol and START-Play, further research is needed to generalize these findings.

Effects of Extracorporeal Shock Wave Therapy on Spasticity in Patients after Brain Injury: A Meta-analysis

[Purpose] The purpose of this meta-analysis was to assess the effects of extracorporeal shock wave therapy (ESWT) on reducing spasticity immediately and 4 weeks after application of ESWT. [Subjects and Methods] We searched PubMed, TCL, Embase, and Scopus from their inception dates through June 2013. The key words "muscle hypertonia OR spasticity" were used for spasticity, and the key words "shock wave OR ESWT" were used for ESWT. Five studies were ultimately included in the meta-analysis. [Results] The Modified Ashworth Scale (MAS) grade was significantly improved immediately after ESWT compared with the baseline values (standardized mean difference [SMD], -0.792; 95% confidence interval [CI], -1.001 to -0.583). The MAS grade at four weeks after ESWT was also significantly improved compared with the baseline values (SMD, -0.735; 95% CI, -0.951 to -0.519). [Conclusion] ESWT has a significant effect on improving spasticity. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow up studies are needed.

Spasticity - Pathogenesis, prevention and treatment strategies

This review of the long-term management of spasticity addresses some of the clinical dilemmas in the management of patients with chronic disability. It is important for clinicians to have clear objectives in patient treatment and the available treatment strategies. The review reiterates the role of physical treatment in the management, and thereafter the maintenance of patients with spasticity. Spasticity is a physiological consequence of an injury to the nervous system. It is a complex problem which can cause profound disability, alone or in combination with the other features of an upper motor neuron syndrome, and can give rise to significant difficulties in the process of rehabilitation. This can be associated with profound restriction to activity and participation due to pain, weakness, and contractures. Optimum management is dependent on an understanding of its underlying physiology, an awareness of its natural history, an appreciation of the impact on the patient, and a comprehensive approach to minimizing that impact. The aim of this article is to highlight the importance, basic approach, and management options available to the general practitioner in such a complex condition.

Evaluation of interadductor approach in neurolytic blockade of obturator nerve in spastic patients

BACKGROUND

Spasticity is a syndrome associated with a persistent increase in involuntary reflex activity of a muscle in response to stretch. Adductor muscle spasticity is a common complication of spinal cord and brain injury. It needs to be treated if it interferes with activities of daily living and self-care. Obturator neurolytic blockade is one of the cost-effective therapeutic possibilities to treat spasticity of adductor group of muscles. In this study, we assessed the efficacy of interadductor approach in alleviating the spasticity.

METHODS

Obturator neurolysis using 8-10 ml 6% phenol was given with the guidance of a peripheral nerve stimulator in 20 spastic patients. Technical evaluation included number of attempted needle insertions, time to accurate location of the nerve, depth of needle insertion, and success rate. Pain, spasticity, hip abduction range of motion (ROM), number of spasms, gait, and hygiene were evaluated at 1(st) hour, 24(th) hour, end of the 1(st) week, and in the 1(st), 2(nd), and 3(rd) months following the intervention.

RESULTS

The success rate was 100% with mean time to accurate nerve location 4.9±2.06 min. Average depth of needle insertion was 2.91±0.32 cm. Compared with the scores measured immediately before the block, all studied parameters improved significantly. An increase in the Modified Ashworth Scale values was observed in the 2(nd) and 3(rd) months, but they did not reach their initial values.

CONCLUSION

The interadductor approach proved to be accurate and fast, with a high success rate. Phenol blockade is an efficient and cost-effective technique in patients with adductor spasticity. It led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene, with an efficacy lasting for about 3 months.

Pharmacologic treatment of spasticity in children

Many clinicians frequently face the dilemma of whether and how to medically treat spasticity. When pharmacologic intervention is deemed appropriate, treatment decisions must first be based on accurate assessment using valid and reliable clinical instruments, and, importantly, specific, measurable, achievable, and realistic treatment goals should be delineated. For the treatment of localized or segmental spasticity, botulinum toxin (BoNT-A) is recommended as an effective and generally safe treatment. For more generalized spasticity, a number of useful oral agents and intrathecal baclofen are available, each with their positive and negative attributes. Fundamental knowledge of pharmacologic properties and toxicities of these medications is required for safe and appropriate use. To achieve optimum results, spasticity treatment should be part of an integrated therapeutic approach in which patients, caregivers, therapists, physicians, and surgeons have an open and clear communication about the overall rehabilitation process of the patient. This review summarizes the current pharmacologic approaches to spasticity treatment in children, critically evaluating published studies in the context of established evidence-based criteria.

Management of spasticity in children with cerebral palsy

Spasticity and other forms of muscle overactivity caused by cerebral palsy may impair function or ease of care or may cause discomfort or poor body image. The treatment program for a child with spasticity may include allied health therapy, exercise, casting, constraint-induced therapy, oral medications, chemodenervation, intrathecal baclofen, selective dorsal rhizotomy, and orthopedic surgery. Techniques may be combined for greater efficacy and better tailoring to the needs of the child. This article provides an overview of each approach, with a review of significant research findings in support of each.

Combining botulinum toxin and phenol to manage spasticity in children

OBJECTIVE

To describe the specific techniques and adverse reactions of using concurrent, multiple injections of both botulinum toxin and phenol to manage spasticity in children with cerebral palsy (CP) and other neurologic conditions.

DESIGN

A retrospective case series.

SETTING

A tertiary care children's hospital.

PARTICIPANTS

Consecutive patients (N=68) with spasticity related to CP or other neurologic conditions.

INTERVENTION

Ninety injection sessions combining botulinum toxin and phenol to manage spasticity.

MAIN OUTCOME MEASURE

Documentation of adverse reactions.

RESULTS

The mean phenol dosage was 9.5mL at a mean of 0.6mL/kg per injection dose. The mean botulinum toxin type A (Botox) dose injected was 193U (12U/kg), and the mean of botulinum toxin type B (Myobloc) dose injected was 7750U (530U/kg). The mean number of muscles injected was 14. Adverse reactions are described but were infrequent. Dysesthetic hand pain occurred in 2 patients. One patient developed a systemic reaction to Myobloc.

CONCLUSIONS

Using botulinum toxin and phenol injections allowed many muscles to be injected to manage spasticity in children with CP and other neurologic conditions. Using this combination allowed an increased number of injections at the maximal recommended dose.

Management of spasticity in children with cerebral palsy

As one component of the upper motor neuron syndrome, spasticity can have a significant functional impact on the child with cerebral palsy. Treatment planning requires the determination that excess tone interferes with some aspect of function, comfort, or care, and takes into consideration carefully devised goals that meet the needs of the patient and the caregiver. Treatment options include physical therapy, oral medications, chemodenervation with botulinum toxin or phenol, rhizotomy, intrathecal baclofen, and orthopedic surgery. The uses and limitations of each is discussed, and evidence for efficacy in cerebral palsy is reviewed.

Treatment of functional limitations at the knee in ambulatory children with cerebral palsy

The gait of ambulatory children with cerebral palsy frequently involves abnormal knee motion. Spasticity, muscle contracture formation, impairments of motor control, weakness, balance deficits, and extrapyramidal motions can all contribute to the functional limitations imposed at the knee. Careful clinical evaluation of the child and their gait must be performed in order to determine the best individual course of treatment. Often, three-dimensional motion analysis with assessment of muscle activity and force is necessary to completely assess the complexities of gait. Several typical gait patterns have been described involving the knee, including 'jump knee', 'crouch', 'true equinus', 'apparent equinus', 'recurvatum' and 'stiff knee' gait. Each of these gait patterns is defined here and discussed using case examples. These typical gait patterns are usually accompanied by involvement at the hip and ankle and may be combined with transverse plane rotational abnormalities. Treatment options such as rehabilitation (physiotherapy, casting, strengthening, and/or orthoses), spasticity management (intramuscular injections of phenol, alcohol, and botulinum toxin type A) and orthopaedic approaches are discussed for each entity.

Spasticity management in the child with spastic quadriplegia

In children with spastic quadriplegia, also described as 'whole body involvement', spasticity can interfere with motor function, contributes to the development of deformities and adversely impacts on care, positioning, and comfort. In this population, spasticity interventions address goals such as improving comfort, reducing pain, easing the burden of carers, slowing the progression of musculoskeletal deformities and perhaps improving function. Children with severe diplegia are distinguished from those with quadriplegia by their ability to ambulate, as well as by a greater emphasis being placed on functional motor goals even though similar treatment modalities are often employed to manage spasticity. The many treatment options currently available include, but are not limited to, botulinum toxin type A, phenol neurolysis, oral medications, intrathecal baclofen, selective dorsal rhizotomy, and orthopaedic surgery. The integration of these treatment modalities can help to optimize the overall care and function for a child with spastic quadriplegia or severe diplegia. However, the development of a management programme is complex and needs to take into account many factors, including age, weight and nutritional status, rate of progression of musculoskeletal deformities, developmental potential, comorbid conditions, current functional status and prognosis, and family and patient treatment goals. Children with marked spasticity are likely to benefit from a combination of interventions, rather than a single treatment modality. Because of these complexities, management should be planned and coordinated by a multidisciplinary team of medical and allied health professionals which recognizes the central role of the family in all decisions. Once the special characteristics of the child with spastic quadriplegia and the various treatment options are understood, outcomes can be maximized.

Phenol block of peripheral nerve conduction: Titrating for optimum effect

OBJECTIVES

To verify the dose-response relationship in phenol nerve block and to determine the concentration and volume of phenol injectate required for effective nerve conduction block.

DESIGN

Before-after, experimental study.

SETTING

A research institute laboratory.

ANIMALS

Seventy-one New Zealand white rabbits.

INTERVENTIONS

Group I (n = 48) received tibial nerve block by perineural injection (phenol, n = 40; saline, n = 8), group II (n = 21) by submerging the nerve in phenol solution. The 6 subgroups of group I each received different concentrations (3%, 4%, 5%) and volumes (0.1mL, 0.2mL, 0.3mL). The 2 subgroups of group II received 3% (n = 8) and 5% (n = 13) phenol.

MAIN OUTCOME MEASURES

Compound muscle action potential (CMAP) and tension of triceps surae muscles by electric stimulation of the sciatic nerve were measured preintervention and at day 1, and weeks 1, 2, 4, and 8 postblock. Histologic studies were performed on 2 animals from group I.

RESULTS

Two rabbits in group I died before results were obtained. In the remaining animals, CMAP amplitude reduced significantly (p <.05) as the volume of 5% phenol solution increased from 0.1mL, 0.2mL, to 0.3mL. A high concentration of phenol produced a more pronounced conduction block; however, no significant (p =.0589) difference existed among the 3 concentrations. Submerged tibial nerve had a greater degree of conduction block than perineurally injected nerve. Depth of the degeneration area in nerve fascicle varied with distance from the injection point.

CONCLUSIONS

The nerve block effect of phenol can be titrated by adjusting the concentration and volume of phenol solution if the technique of application and localization of a block site are standardized.

Treatment of neuromuscular and musculoskeletal problems in cerebral palsy

Cerebral palsy typically involves a variety of neuromuscular and musculoskeletal problems. These problems include spasticity, dystonia, contractures, abnormal bone growth, poor balance, and loss of selective motor control. These problems can interfere with function and treating them can improve function. The treatments include physical and occupational therapy, bracing, oral medications, neurolytic blocks, neurosurgical procedures, orthopaedic surgery and others. Using a multidisciplinary treatment team with a good understanding of cerebral palsy, the best treatment options can be determined and functional outcomes maximized.

The surgical treatment of spasticity

Many neurosurgical procedures have been designed for or applied to the treatment of spasticity arising from different disorders, including cerebral palsy; traumatic, ischemic, or hypoxic brain injury, multiple sclerosis, and spinal cord injury. Neurosurgical procedures are primarily aimed at reducing spasticity by interrupting the stretch reflex at various sites along the spinal reflex arc or attempting to increase the centrally mediated inhibitory influence on the pool of motor neurons in the anterior horn. Surgical interventions for spasticity can be classified into peripheral ablative procedures, such as rhizotomy or peripheral neurectomy, and central ablative procedures, such as cordectomy, myelotomy, or stereotactic procedures. Non-ablative procedures include peripheral nerve or motor point blocks, the implantation of cerebellar or spinal stimulators, and the implantation of subdural catheters for infusion of pharmacologic agents to increase inhibitory activity. Several proposed mechanisms for spasticity are reviewed so that the rationale for the various surgical interventions for spasticity described may be better understood.

Subcutaneous bupivacaine for treatment of spasticity: a case report

In a previous report, we described heretofore undiscovered possibilities that neuropathic pain and spasticity may share some common pathophysiological mechanisms. Currently, systemically delivered local anesthetics are being used for the evaluation and treatment of neuropathic pain. We present a case describing the treatment of spasticity of spinal origin with continuous subcutaneous infusion of 0.75% bupivacaine in a patient who did not respond to traditional treatments and has become tolerant to intrathecal baclofen.