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Spasticity, Dystonia, and Athetosis Management in the Upper Extremity in Cerebral Palsy

  • Freeman Miller
Living reference work entry

Abstract

Upper extremity disability from cerebral palsy (CP) in both children and adults has multiple aspects to the impairment. Increase muscle spasticity and movement disorder are very common and may be predominating symptoms of the impaired limb. It should be noted, however, that these are often combined with muscle contractures, decreased selective motor control, impaired sensibility, and overall ignoring the limb. The topic of upper extremity spasticity has received as much or more attention than lower extremity spasticity in CP. There are multiple mechanisms for assessing spasticity, which is an issue that continues to be unresolved. In addition to spasticity, movement disorders both athetosis and dystonia are relatively common manifestations of the upper extremity impairment. Treatment for upper extremity spasticity includes many different modalities from oral medication, botulinum toxin injection, electrical stimulation, neurectomy, therapy, and transcranial stimulation. Treatment for movement disorders includes oral medication, intrathecal baclofen, and deep brain stimulation. For the whole population of all children with cerebral palsy, approximately 60% have significant upper extremity disability. The vast majority of these are individuals with spasticity; however approximately 20% also report dyskinetic movement disorders in the upper extremity. The goal for this chapter is to define the treatment options for spasticity and movement disorders in the upper extremity of individuals with CP. The risks, complications, and longer-term expectations of these management strategies will also be discussed.

Keywords

Cerebral palsy Dystonia Spasticity Athetosis Chorea Intrathecal baclofen Deep brain stimulation (DBS) Intrathecal baclofen (ITB) 

References

  1. Albright AL (1996a) Baclofen in the treatment of cerebral palsy. Neurology 11:77–83. SRC – GoogleScholarGoogle Scholar
  2. Albright AL (1996b) Intrathecal baclofen in cerebral palsy movement disorders. Neurology 11(Suppl 1):S29–S35. SRC – GoogleScholarGoogle Scholar
  3. Albright AL, Cervi A, Singletary J (1991) Intrathecal baclofen for spasticity in cerebral palsy [see comments]. JAMA 265:1418–1422. SRC – GoogleScholarCrossRefPubMedGoogle Scholar
  4. Aravamuthan BR, Waugh JL (2016) Localization of basal ganglia and thalamic damage in dyskinetic cerebral palsy. Pediatr Neurol 54:11–21CrossRefPubMedGoogle Scholar
  5. Aree-uea B, Auvichayapat N, Janyacharoen T, Siritaratiwat W, Amatachaya A, Prasertnoo J, Tunkamnerdthai O, Thinkhamrop B, Jensen MP, Auvichayapat P (2014) Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation. J Med Assoc Thail 97:954–962Google Scholar
  6. Arner M, Eliasson AC, Nicklasson S, Sommerstein K, Hagglund G (2008) Hand function in cerebral palsy. Report of 367 children in a population-based longitudinal health care program. J Hand Surg [Am] 33:1337–1347CrossRefGoogle Scholar
  7. Austin A, Lin JP, Selway R, Ashkan K, Owen T (2017) What parents think and feel about deep brain stimulation in paediatric secondary dystonia including cerebral palsy: a qualitative study of parental decision-making. Eur J Paediatr Neurol 21(1):185–192Google Scholar
  8. Autti-Ramo I, Larsen A, Taimo A, von Wendt L (2001) Management of the upper limb with botulinum toxin type A in children with spastic type cerebral palsy and acquired brain injury: clinical implications. Eur J Neurol 8(Suppl 5):136–144CrossRefPubMedGoogle Scholar
  9. Beck AJ, Gaskill SJ, Marlin AE, J. (1993) Improvement in upper extremity function and trunk control after selective posterior rhizotomy. Am Ther 47:704–707. SRC – GoogleScholarGoogle Scholar
  10. Ben-Pazi H (2011) Trihexyphenidyl improves motor function in children with dystonic cerebral palsy: a retrospective analysis. J Child Neurol 26:810–816CrossRefPubMedGoogle Scholar
  11. Buckon CE, Thomas S, Aiona MD, Piatt JH (1996) Sienko assessment of upper-extremity function in children with spastic diplegia before and after selective dorsal rhizotomy. Dev Med Child Neurol 38:967–975. SRC – GoogleScholarCrossRefPubMedGoogle Scholar
  12. Chin TY, Duncan JA, Johnstone BR, Graham HK (2005) Management of the upper limb in cerebral palsy. J Pediatr Orthop B 14:389–404CrossRefPubMedGoogle Scholar
  13. Corry IS, Cosgrove AP, Walsh EG, McClean D, Graham HK (1997) Botulinum toxin A in the hemiplegic upper limb: a double-blind trial [see comments]. Dev Med Child Neurol 39:185–193. SRC – GoogleScholarCrossRefPubMedGoogle Scholar
  14. De Rinaldis M, Losito L, Gennaro L, Trabacca A (2010) Long-term oral baclofen treatment in a child with cerebral palsy: electroencephalographic changes and clinical adverse effects. J Child Neurol 25:1272–1274CrossRefPubMedGoogle Scholar
  15. Fehlings D, Rang M, Glazier J, Steele C (2001) Botulinum toxin type A injections in the spastic upper extremity of children with hemiplegia: child characteristics that predict a positive outcome. Eur J Neurol 8(Suppl 5):145–149CrossRefPubMedGoogle Scholar
  16. Fitoussi F, Ilharreborde B, Presedo A, Souchet P, Pennecot GF, Mazda K (2010) Shoulder external rotator selective neurotomy in cerebral palsy: anatomical study and preliminary clinical results. J Pediatr Orthop B 19:71–76CrossRefPubMedGoogle Scholar
  17. Fletcher NA, Thompson PD, Scadding JW, Marsden CD (1993) Successful treatment of childhood onset symptomatic dystonia with levodopa. J Neurol Neurosurg Psychiatry 56:865–867CrossRefPubMedPubMedCentralGoogle Scholar
  18. Francisco GE (2006) Successful treatment of posttraumatic hemiballismus with intrathecal baclofen therapy. Am J Phys Med Rehabil 85:779–782CrossRefPubMedGoogle Scholar
  19. Gilmartin R, Bruce D, Storrs BB, J. (2000) Intrathecal baclofen for management of spastic cerebral palsy: multicenter trial. Neurology 15:71–77. SRC – GoogleScholarGoogle Scholar
  20. Gooch JL, Patton CP (2004) Combining botulinum toxin and phenol to manage spasticity in children. Arch Phys Med Rehabil 85:1121–1124CrossRefPubMedGoogle Scholar
  21. Goyal V, Laisram N, Wadhwa RK, Kothari SY (2016) Prospective randomized study of oral diazepam and baclofen on spasticity in cerebral palsy. J Clin Diagn Res 10:RC01–RC05PubMedPubMedCentralGoogle Scholar
  22. Gracies JM, Elovic E, McGuire J, Simpson DM, Part I (1997) Traditional pharmacological treatments for spasticity. Local Treat Muscle Nerve Suppl 6:S61–S91. SRC – GoogleScholarCrossRefPubMedGoogle Scholar
  23. Hagglund G, Wagner P (2008) Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 9:150CrossRefPubMedPubMedCentralGoogle Scholar
  24. Halpern R, Gillard P, Graham GD, Varon SF, Zorowitz RD (2013) Adherence associated with oral medications in the treatment of spasticity. PM R 5:747–756CrossRefPubMedGoogle Scholar
  25. Hansel DE, Hansel CR, Shindle MK, Reinhardt EM, Madden L, Levey EB, Johnston MV, Hoon AH Jr (2003) Oral baclofen in cerebral palsy: possible seizure potentiation? Pediatr Neurol 29:203–206CrossRefPubMedGoogle Scholar
  26. Hoon AH Jr, Freese PO, Reinhardt EM, Wilson MA, Lawrie WT Jr, Harryman SE, Pidcock FS, Johnston MV (2001) Age-dependent effects of trihexyphenidyl in extrapyramidal cerebral palsy. Pediatr Neurol 25:55–58CrossRefPubMedGoogle Scholar
  27. Hurvitz EA, Conti GE, Brown SH (2003) Changes in movement characteristics of the spastic upper extremity after botulinum toxin injection. Arch Phys Med Rehabil 84:444–454CrossRefPubMedGoogle Scholar
  28. Jan MM (2004) Misdiagnoses in children with dopa-responsive dystonia. Pediatr Neurol 31:298–303CrossRefPubMedGoogle Scholar
  29. Jethwa A, Mink J, Macarthur C, Knights S, Fehlings T, Fehlings D (2010) Development of the hypertonia assessment tool (HAT): a discriminative tool for hypertonia in children. Dev Med Child Neurol 52:e83–e87CrossRefPubMedGoogle Scholar
  30. Jones MH (1953) What’s new in cerebral palsy. Calif Med 79:357–361PubMedPubMedCentralGoogle Scholar
  31. Kamal N, Bhat DP, Carrick E (2006) Dopa-responsive dystonia (Segawa syndrome). Indian Pediatr 43:635–638PubMedGoogle Scholar
  32. Kamper DG, Yasukawa AM, Barrett KM, Gaebler-Spira DJ (2006) Effects of neuromuscular electrical stimulation treatment of cerebral palsy on potential impairment mechanisms: a pilot study. Pediatr Phys Ther 18:31–38CrossRefPubMedGoogle Scholar
  33. Koy A, Hellmich M, Pauls KA, Marks W, Lin JP, Fricke O, Timmermann L (2013) Effects of deep brain stimulation in dyskinetic cerebral palsy: a meta-analysis. Mov Disord 28:647–654CrossRefPubMedGoogle Scholar
  34. Koy A, Pauls KA, Flossdorf P, Becker J, Schonau E, Maarouf M, Liebig T, Fricke O, Fink GR, Timmermann L (2014) Young adults with dyskinetic cerebral palsy improve subjectively on pallidal stimulation, but not in formal dystonia, gait, speech and swallowing testing. Eur Neurol 72:340–348CrossRefPubMedGoogle Scholar
  35. Loewen P, Steinbok P, Holsti L, MacKay M (1998) Upper extremity performance and self-care skill changes in children with spastic cerebral palsy following selective posterior rhizotomy. Pediatr Neurosurg 29:191–198. SRC – GoogleScholarCrossRefPubMedGoogle Scholar
  36. Mackey AH, Walt SE, Lobb G, Stott NS (2004) Intraobserver reliability of the modified Tardieu scale in the upper limb of children with hemiplegia. Dev Med Child Neurol 46:267–272CrossRefPubMedGoogle Scholar
  37. Marks WA, Honeycutt J, Acosta F Jr, Reed M, Bailey L, Pomykal A, Mercer M (2011) Dystonia due to cerebral palsy responds to deep brain stimulation of the globus pallidus internus. Mov Disord 26:1748–1751CrossRefPubMedGoogle Scholar
  38. Marks W, Bailey L, Reed M, Pomykal A, Mercer M, Macomber D, Acosta F Jr, Honeycutt J (2013) Pallidal stimulation in children: comparison between cerebral palsy and DYT1 dystonia. J Child Neurol 28:840–848CrossRefPubMedGoogle Scholar
  39. Monbaliu E, Ortibus E, Roelens F, Desloovere K, Deklerck J, Prinzie P, de Cock P, Feys H (2010) Rating scales for dystonia in cerebral palsy: reliability and validity. Dev Med Child Neurol 52:570–575CrossRefPubMedGoogle Scholar
  40. Monbaliu E, De Cock P, Mailleux L, Dan B, Feys H (2017) The relationship of dystonia and choreoathetosis with activity, participation and quality of life in children and youth with dyskinetic cerebral palsy. Eur J Paediatr Neurol 21(2):327-335Google Scholar
  41. Montane E, Vallano A, Laporte JR (2004) Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review. Neurology 63:1357–1363CrossRefPubMedGoogle Scholar
  42. Numanoglu A, Gunel MK (2012) Intraobserver reliability of modified Ashworth scale and modified Tardieu scale in the assessment of spasticity in children with cerebral palsy. Acta Orthop Traumatol Turc 46:196–200CrossRefPubMedGoogle Scholar
  43. Ozer K, Chesher SP, Scheker LR (2006) Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Dev Med Child Neurol 48:559–563CrossRefPubMedGoogle Scholar
  44. Park HS, Kim J, Damiano DL (2012) Development of a Haptic Elbow Spasticity Simulator (HESS) for improving accuracy and reliability of clinical assessment of spasticity. IEEE Trans Neural Syst Rehabil Eng 20:361–370CrossRefPubMedPubMedCentralGoogle Scholar
  45. Reeuwijk A, van Schie PE, Becher JG, Kwakkel G (2006) Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review. Clin Rehabil 20:375–387CrossRefPubMedGoogle Scholar
  46. Romito LM, Zorzi G, Marras CE, Franzini A, Nardocci N, Albanese A (2015) Pallidal stimulation for acquired dystonia due to cerebral palsy: beyond 5 years. Eur J Neurol 22:426–e32CrossRefPubMedGoogle Scholar
  47. Saintyves G, Genet F, Allieu Y, Judet T, Denormandie P (2011) Surgical management of spasticity of the intrinsic muscles of the long fingers in adults after cerebral palsy, 68 operated hands. Chir Main 30:46–51CrossRefPubMedGoogle Scholar
  48. Sanger TD, Bastian A, Brunstrom J, Damiano D, Delgado M, Dure L, Gaebler-Spira D, Hoon A, Mink JW, Sherman-Levine S, Welty LJ, Group Child Motor Study (2007) Prospective open-label clinical trial of trihexyphenidyl in children with secondary dystonia due to cerebral palsy. J Child Neurol 22:530–537CrossRefPubMedGoogle Scholar
  49. Satila H, Kotamaki A, Koivikko M, Autti-Ramo I (2006) Upper limb function after botulinum toxin A treatment in cerebral palsy: two years follow-up of six cases. Pediatr Rehabil 9:247–258CrossRefPubMedGoogle Scholar
  50. Speth L, Janssen-Potten Y, Leffers P, Rameckers E, Defesche A, Winkens B, Becher J, Smeets R, Vles JS (2015) Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity impairments in unilateral cerebral palsy: an explorative study. Eur J Paediatr Neurol 19:337–348CrossRefPubMedGoogle Scholar
  51. Taira T, Hori T (2007) Intrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state. Acta Neurochir Suppl 97:227–229PubMedGoogle Scholar
  52. Taira T, Hori T (2008) Selective peripheral neurotomy and selective dorsal rhizotomy. Brain Nerve 60:1427–1436PubMedGoogle Scholar
  53. Taira T, Ochiai T, Goto S, Hori T (2006) Fifteen year experience of intrathecal baclofen treatment in Japan. Acta Neurochir Suppl 99:61–63CrossRefPubMedGoogle Scholar
  54. Valle AC, Dionisio K, Pitskel NB, Pascual-Leone A, Orsati F, Ferreira MJ, Boggio PS, Lima MC, Rigonatti SP, Fregni F (2007) Low and high frequency repetitive transcranial magnetic stimulation for the treatment of spasticity. Dev Med Child Neurol 49:534–538CrossRefPubMedGoogle Scholar
  55. Van Heest AE, Bagley A, Molitor F, James MA (2015) Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg Am 97:529–536CrossRefPubMedGoogle Scholar
  56. 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: CD003469Google Scholar
  57. Yildizgoren MT, Nakipoglu Yuzer GF, Ekiz T, Ozgirgin N (2014) Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy. Pediatr Neurol 51:360–364CrossRefPubMedGoogle Scholar
  58. Zancolli EA (2003) Surgical management of the hand in infantile spastic hemiplegia. Hand Clin 19:609–629CrossRefPubMedGoogle Scholar
  59. Zonta MB, Bruck I, Puppi M, Muzzolon S, Neto Ade C, Coutinho dos Santos LH (2013) Effects of early spasticity treatment on children with hemiplegic cerebral palsy: a preliminary study. Arq Neuropsiquiatr 71:453–461CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

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