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Focal Management of Spasticity in Cerebral Palsy

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Abstract

Spasticity is the most common presentation of all neurologic alterations in children with CP. When the neurologic system loses motor control function and postural stability or weakens but has organizational ability to functionally respond, it will increase muscle tone to compensate. However, there are cases where this response over reacts and it develops pathologic spasticity which causes impairment. Therefore, when treating children with spasticity, the basic supposition is that muscle tone is good and the amount of muscle tone should be modulated for the individual’s maximum benefit. Spasticity may be generalized affecting almost all the muscular system, and generalized increase in tone may be associated with mixed tone conditions where it is combined with movement disorders. The spasticity for these individuals may be very beneficial to modulate the movement disorder. Treatments for generalized spasticity require an approach that reduces whole body tone. Children with diplegia often have more localized spasticity problems such as the plantar flexors but may also involve the whole lower extremities. Management options include whole body methods. In children with hemiplegia or unilateral CP, the spasticity tends to be localized to a single side, and the treatment should be more focused on the local problem. There are many treatment options for spasticity including those that affect the whole body to those that have a very localized affect. Some of the treatments also are permanent and cannot be reversed, while others are temporary whose effect disappears when the treatment ends. The remaining discussion in this chapter will focus on the localized effects of spasticity and localized treatments of spasticity.

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References

  • Baird MW, Vargus-Adams J (2010) Outcome measures used in studies of botulinum toxin in childhood cerebral palsy: a systematic review. J Child Neurol 25:721–727

    Article  PubMed  Google Scholar 

  • Barwood S, Baillieu C, Boyd R, Brereton K, Low J, Nattrass G, Graham HK (2000) Analgesic effects of botulinum toxin A: a randomized, placebo-controlled clinical trial. Dev Med Child Neurol 42:116–121

    Article  CAS  PubMed  Google Scholar 

  • Bertoti DB (1986) Effect of short leg casting on ambulation in children with cerebral palsy. Phys Ther 66:1522–1529

    Article  CAS  PubMed  Google Scholar 

  • Bonner PH, Friedli AF, Baker RS (1994) Botulinum A toxin stimulates neurite branching in nerve-muscle cocultures. Brain Res Dev Brain Res 79:39–46

    Article  CAS  PubMed  Google Scholar 

  • Borodic GE, Ferrante R, Pearce LB, Smith K (1994) Histologic assessment of dose-related diffusion and muscle fiber response after therapeutic botulinum A toxin injections. Mov Disord 9:31–39

    Article  CAS  PubMed  Google Scholar 

  • Brin MF (1997) Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 6:S146–S168

    Article  CAS  PubMed  Google Scholar 

  • Calderon-Gonzalez R, Calderon-Sepulveda RF (2002) Clinical treatment (non surgical) of spasticity in cerebral palsy. Rev Neurol 34:1–6

    PubMed  CAS  Google Scholar 

  • Carpenter EB (1983) Role of nerve blocks in the foot and ankle in cerebral palsy: therapeutic and diagnostic. Foot Ankle 4:164–166

    Article  CAS  PubMed  Google Scholar 

  • Carpenter EB, Seitz DG (1980) Intramuscular alcohol as an aid in management of spastic cerebral palsy. Dev Med Child Neurol 22:497–501

    Article  CAS  PubMed  Google Scholar 

  • Castle ME, Reyman TA, Schneider M (1979) Pathology of spastic muscle in cerebral palsy. Clin Orthop Relat Res 142:223–32

    Google Scholar 

  • Connolly KJ, Forssberg H (1997) Neurophysiology & neuropsychology of motor development. London, Mac Keith Press

    Google Scholar 

  • Crenshaw S, Herzog R, Castagno P, Richards J, Miller F, Michaloski G, Moran E (2000) The efficacy of tone-reducing features in orthotics on the gait of children with spastic diplegic cerebral palsy. J Pediatr Orthop 20:210–216

    PubMed  CAS  Google Scholar 

  • Delgado MR, Bonikowski M, Carranza J, Dabrowski E, Matthews D, Russman B, Tilton A, Velez JC, Grandoulier AS, Picaut P (2017) Safety and efficacy of repeat open-label abobotulinumtoxinA treatment in pediatric cerebral palsy. J Child Neurol 32:1058–1064

    Article  PubMed  PubMed Central  Google Scholar 

  • Deltombe T, Gustin T, Laloux P, De Cloedt P, De Wispelaere JF, Hanson P (2001) Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children. Acta Orthop Belg 67:1–5

    PubMed  CAS  Google Scholar 

  • Dietz V, Berger W (1995) Cerebral palsy and muscle transformation. Dev Med Child Neurol 37:180–184

    Article  CAS  PubMed  Google Scholar 

  • Doute DA, Sponseller PD, Tolo VT, Atkins E, Silberstein CE (1997) Soleus neurectomy for dynamic ankle equinus in children with cerebral palsy. Am J Orthop (Belle Mead NJ) 26:613–616

    CAS  Google Scholar 

  • Fehlings D (2005) The use of botulinum toxin in paediatric hypertonia. Paediatr Child Health 10:379–381

    PubMed  PubMed Central  Google Scholar 

  • Fonseca PR Jr, Franco de Moura RC, Galli M, Santos Oliveira C (2017) Effect of physiotherapeutic intervention on the gait after the application of botulinum toxin in children with cerebral palsy: systematic review. Eur J Phys Rehabil Med. https://doi.org/10.23736/S1973-9087.17.04940-1. [Epub ahead of print]

  • Fortuna R, Horisberger M, Vaz MA, Herzog W (2013) Do skeletal muscle properties recover following repeat onabotulinum toxin A injections? J Biomech 46:2426–2433

    Article  PubMed  Google Scholar 

  • Fortuna R, Vaz MA, Sawatsky A, Hart DA, Herzog W (2015) A clinically relevant BTX-A injection protocol leads to persistent weakness, contractile material loss, and an altered mRNA expression phenotype in rabbit quadriceps muscles. J Biomech 48:1700–1706

    Article  PubMed  Google Scholar 

  • Ghai A, Sangwan SS, Hooda S, Kiran S, Garg N (2012) Obturator neurolysis using 65% alcohol for adductor muscle spasticity. Saudi J Anaesth 6:282–284

    Article  PubMed  PubMed Central  Google Scholar 

  • Gooch JL, Patton CP (2004) Combining botulinum toxin and phenol to manage spasticity in children. Arch Phys Med Rehabil 85:1121–1124

    Article  PubMed  Google Scholar 

  • Hagglund G, Wagner P (2008) Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 9:150

    Article  PubMed  PubMed Central  Google Scholar 

  • Hart DA, Fortuna R, Herzog W (2017) Messenger RNA profiling of rabbit quadriceps femoris after repeat injections of botulinum toxin: evidence for a dynamic pattern without further structural alterations. Muscle Nerve 57:487–493

    Article  CAS  PubMed  Google Scholar 

  • Hoare BJ, Wallen MA, Imms C, Villanueva E, Rawicki HB, Carey L (2010) Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database Syst Rev 1:CD003469

    Google Scholar 

  • Jankovic J, Brin MF (1997) Botulinum toxin: historical perspective and potential new indications. Muscle Nerve Suppl 6:S129–S145

    Article  CAS  PubMed  Google Scholar 

  • Kawamura A, Campbell K, Lam-Damji S, Fehlings D (2007) A randomized controlled trial comparing botulinum toxin A dosage in the upper extremity of children with spasticity. Dev Med Child Neurol 49:331–337

    Article  PubMed  Google Scholar 

  • Khot A, Sloan S, Desai S, Harvey A, Wolfe R, Graham HK (2008) Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children. J Child Orthop 2:293–299

    Article  PubMed  PubMed Central  Google Scholar 

  • Kolaski K, Ajizian SJ, Passmore L, Pasutharnchat N, Koman LA, Smith BP (2008) Safety profile of multilevel chemical denervation procedures using phenol or botulinum toxin or both in a pediatric population. Am J Phys Med Rehabil 87:556–566

    Article  PubMed  Google Scholar 

  • Kuehn BM (2009) FDA requires black box warnings on labeling for botulinum toxin products. JAMA 301:2316

    Article  CAS  PubMed  Google Scholar 

  • Kwon JY, Kim JS (2009) Selective blocking of the anterior branch of the obturator nerve in children with cerebral palsy. Am J Phys Med Rehabil 88:7–13

    Article  PubMed  Google Scholar 

  • Lin JP, Brown JK, Walsh EG (1996) The maturation of motor dexterity: or why Johnny can’t go any faster. Dev Med Child Neurol 38:244–254

    Article  CAS  PubMed  Google Scholar 

  • Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, O’Flaherty S, Graham HK, Institute Cerebral Palsy (2010) Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. Eur J Neurol 17(Suppl 2):9–37

    Article  PubMed  Google Scholar 

  • Ma J, Shen J, Lee CA, Elsaidi GA, Smith TL, Walker FO, Rushing JT, Tan KH, Koman LA, Smith BP (2005) Gene expression of nAChR, SNAP-25 and GAP-43 in skeletal muscles following botulinum toxin A injection: a study in rats. J Orthop Res 23:302–309

    Article  CAS  PubMed  Google Scholar 

  • Matsuo T, Tada S, Hajime T (1986) Insufficiency of the hip adductor after anterior obturator neurectomy in 42 children with cerebral palsy. J Pediatr Orthop 6:686–692

    Article  CAS  PubMed  Google Scholar 

  • Miller F, Slomczykowski M, Cope R, Lipton GE (1999) Computer modeling of the pathomechanics of spastic hip dislocation in children. J Pediatr Orthop 19:486–492

    Article  CAS  PubMed  Google Scholar 

  • Molenaers G, Van Campenhout A, Fagard K, De Cat J, Desloovere K (2010) The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb. J Child Orthop 4:183–195

    Article  PubMed  PubMed Central  Google Scholar 

  • Msaddi AK, Mazroue AR, Shahwan S, al Amri N, Dubayan N, Livingston D, Moutaery KR (1997) Microsurgical selective peripheral neurotomy in the treatment of spasticity in cerebral-palsy children. Stereotact Funct Neurosurg 69:251–258

    Article  CAS  PubMed  Google Scholar 

  • Otis JC, Root L, Kroll MA (1985) Measurement of plantar flexor spasticity during treatment with tone-reducing casts. J Pediatr Orthop 5:682–686

    Article  CAS  PubMed  Google Scholar 

  • Park ES, Rha DW, Lee WC, Sim EG (2014) The effect of obturator nerve block on hip lateralization in low functioning children with spastic cerebral palsy. Yonsei Med J 55:191–196

    Article  CAS  PubMed  Google Scholar 

  • Ploypetch T, Kwon JY, Armstrong HF, Kim H (2015) A retrospective review of unintended effects after single-event multi-level chemoneurolysis with botulinum toxin-A and phenol in children with cerebral palsy. PMR 7:1073–1080

    Article  Google Scholar 

  • Quality Standards Subcommittee of the American Academy of Neurology, Society the Practice Committee of the Child Neurology, Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, McLaughlin J, Morrison LA, Shrader MW, Tilton A, Vargus-Adams J (2010) Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 74:336–343

    Article  Google Scholar 

  • Rawicki B, Sheean G, Fung VS, Goldsmith S, Morgan C, Novak I, Institute Cerebral Palsy (2010) Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement. Eur J Neurol 17(Suppl 2):122–134

    Article  PubMed  Google Scholar 

  • Ricks NR, Eilert RE (1993) Effects of inhibitory casts and orthoses on bony alignment of foot and ankle during weight-bearing in children with spasticity. Dev Med Child Neurol 35:11–16

    Article  CAS  PubMed  Google Scholar 

  • Robinson KG, Mendonca JL, Militar JL, Theroux MC, Dabney KW, Shah SA, Miller F, Akins RE (2013) Disruption of basal lamina components in neuromotor synapses of children with spastic quadriplegic cerebral palsy. PLoS One 8:e70288

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Rogozhin AA, Pang KK, Bukharaeva E, Young C, Slater CR (2008) Recovery of mouse neuromuscular junctions from single and repeated injections of botulinum neurotoxin A. J Physiol 586:3163–3182

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Ryll U, Bastiaenen C, De Bie R, Staal B (2011) Effects of leg muscle botulinum toxin A injections on walking in children with spasticity-related cerebral palsy: a systematic review. Dev Med Child Neurol 53:210–216

    Article  PubMed  Google Scholar 

  • Schroeder AS, Ertl-Wagner B, Britsch S, Schroder JM, Nikolin S, Weis J, Muller-Felber W, Koerte I, Stehr M, Berweck S, Borggraefe I, Heinen F (2009) Muscle biopsy substantiates long-term MRI alterations one year after a single dose of botulinum toxin injected into the lateral gastrocnemius muscle of healthy volunteers. Mov Disord 24:1494–1503

    Article  PubMed  Google Scholar 

  • Sharma S, Mishra KS, Dutta A, Kulkarni SK, Nair MN (1989) Intrapelvic obturator neurectomy in cerebral palsy. Indian J Pediatr 56:259–265

    Article  CAS  PubMed  Google Scholar 

  • Tilton AH (2003) Injectable neuromuscular blockade in the treatment of spasticity and movement disorders. J Child Neurol 18(Suppl 1):S50–S66

    Article  PubMed  Google Scholar 

  • Wasiak J, Hoare B, Wallen M (2004) Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Cochrane Database Syst Rev 4:CD003469

    Google Scholar 

  • Willoughby K, Ang SG, Thomason P, Graham HK (2012) The impact of botulinum toxin A and abduction bracing on long-term hip development in children with cerebral palsy. Dev Med Child Neurol 54:743–747

    Article  PubMed  Google Scholar 

  • Wong AM, Chen CL, Chen CP, Chou SW, Chung CY, Chen MJ (2004) Clinical effects of botulinum toxin A and phenol block on gait in children with cerebral palsy. Am J Phys Med Rehabil 83:284–291

    Article  PubMed  Google Scholar 

  • Wong C, Pedersen SA, Kristensen BB, Gosvig K, Sonne-Holm S (2015) The effect of botulinum toxin A injections in the spine muscles for cerebral palsy scoliosis, examined in a prospective, randomized triple-blinded study. Spine (Phila Pa 1976) 40:E1205–E1211

    Article  Google Scholar 

  • Yang EJ, Rha DW, Kim HW, Park ES (2008) Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy. Arch Phys Med Rehabil 89:2108–2113

    Article  PubMed  Google Scholar 

  • Ziv I, Blackburn N, Rang M, Koreska J (1984) Muscle growth in normal and spastic mice. Dev Med Child Neurol 26:94–99

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. AI DuPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

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  1. Freeman Miller
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Correspondence to Freeman Miller .

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Editors and Affiliations

  1. Alfred I. duPont Institute, Wilmington, DE, USA

    Freeman Miller

  2. Cerebral Palsy Program, AI DuPont Hospital for Children , Wilmington, DE, USA

    Steven Bachrach

  3. AI DuPont Hospital for Children , Wilmington, DE, USA

    Nancy Lennon

  4. Drexel University, PHILADELPHIA, PA, USA

    Margaret O'Neil

Section Editor information

  1. Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

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Miller, F. (2018). Focal Management of Spasticity in Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M. (eds) Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-319-50592-3_43-1

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  • DOI: https://doi.org/10.1007/978-3-319-50592-3_43-1

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-50592-3

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