CP Factsheet Medical and surgical treatments to treat spasticity
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The most common therapy used for treating the spasticity associated with cerebral palsy is physiotherapy. Physiotherapy (as outlined in Capability Scotland’s CP factsheet, ‘Introduction to Therapy’) is the treatment of disorders of movement and function through exercise, manipulation, heat, as well as electrical or ultrasonic procedures. Besides physiotherapy, there are a number of medical and surgical procedures available that are used to manage spasticity. This factsheet looks at three relatively new medical and surgical techniques. Intrathecal Baclofen Therapy
Baclofen is a muscle relaxant drug used to relieve the stiffness caused by spasticity (tight and stiff muscle tone). However, when taken orally (by mouth) it can have side effects in some people, including lethargy and loss of balance. Intrathecal Baclofen Infusion Therapy (ITB) was developed to deliver Baclofen directly into the spinal fluid by a pump implanted under the skin in the abdomen. By putting the Baclofen directly into the spinal fluid, the drug can act as a muscle relaxant and reduce spasticity in the lower limbs without the side effects associated with taking the drug orally. The Baclofen pump is the size of ice hockey puck (about 3cms in diameter) and is inserted into the abdominal cavity in an operation lasting about 50 minutes. The pump then delivers a small amount of Baclofen into the spinal fluid via a small tube. A computer turns the pump on and the dose of Baclofen can be adjusted up or down, depending on the individual’s response to the drug. The pump needs to be refilled about every two months by inserting a needle into the pump through the skin. The pump will need to be replaced after five or six years.
Children (as young as 5 years) as well as adults have received ITB. However the treatment is not suitable for everyone who has cerebral palsy. It does not help people with low muscle tone (often described as floppy muscles), chorea (uncontrollable, small jerky movements of toes and fingers), or athetosis (involuntary movements of face, arms and trunk). Further Information
You can find more information about ITB from: University Hospital Nottingham Centre QMC campus Derby Road Nottingham NG7 2UH Tel: 01159 249 924 ext. 63635 Website: www.baclofen.info References
Awaad Y, et al. Functional assessment following intrathecal baclofen therapy in children with spastic cerebral palsy. Journal of Child Neurology 2003; 18: 26-34
Krach LE, et al. GMFM 1 year after continuous intrathecal baclofen infusion. Pediatric Rehab 2005; 8 (3): 207-213
Gerszten PC, Albright AL, Johnstone GF. Intrathecal baclofen infusion and subsequent orthopaedic surgery in patients with spastic cerebral palsy. Journal of Neurosurgery 1998; 88 1009-1013
Krach LE, Kriel RS, Gilmartin RC et al. Hip status in cerebral palsy after one year of continuous intrathecal baclofen infusion. Pediatric Neurology 2004;30: 163-168
Gilmartin R, Bruce D, et al. Intrathecal baclofen for management of spastic cerebral palsy; multicenter trial. Journal of Child Neurology 2000; 71-77
Selective Dorsal Rhizotomy
Selective dorsal rhizotomy is a neurosurgical procedure used to treat spasticity in the lower limbs. The treatment aims to reduce spasticity, increase range of movement and improve body positioning and walking in those who can walk. The surgery involves cutting sensory nerve fibres in the spinal cord in the lower area of the back. With cerebral palsy, these sensory nerves do not function effectively, and this is thought to contribute to spasticity. By identifying and cutting those nerve fibres which are not ‘transmitting’ effectively, the aim is to reduce muscle tone.
This is major surgery requiring a general anaesthetic. The duration of the operation is likely to be about 5 hours. The treatment is not suitable for everyone with cerebral palsy. Factors which appear to contribute to the success of the surgery include:
The ability to participate in post-operative therapy
After surgery, intensive physiotherapy will be required for around 3 months to 1 year. There are two UK centres currently offering this treatment: the Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire and the Frenchay Hospital, North Bristol. Each hospital has their own selection criteria and referrals must be made through your GP. Selective dorsal rhizotomy is a relatively new, and in some ways controversial intervention which has not yet been subjected to adequate controlled trials. Reports are mixed regarding the long-term effects on function. Full evidence of any side effects is not yet available. Further information
The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust Oswestry Shropshire SY10 7AG Tel: 01691 404 000 Fax: 01691 404 050 Website: www.rjah.nhs.uk
Frenchay Hospital Frenchay Park Road Bristol BS16 1LE Tel: 0117 970 1212 Website:www.nbt.nhs.uk References
What’s the Evidence? Selective Dorsal Rhizotomy published by Cerebra (www.cerebra.org.uk) This document also lists a number of research papers and clinical trials which have been published about SDR.
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (2010) published by National Institute for Health and Clinical Excellence (NICE).
Grunt S, Becher JG, van Schie P, van Ouwerkerk WJ, Ahmade M, Vermeulen RJ. Childs Nerv Syst. 2009 Oct 13. (Epub ahead of print). Preoperative MRI findings and functional outcome after selective dorsal rhizotomy in children with bilateral spasticity.
Engsberg JR, Ross SA, Collins DR, Park TS. Predicting functional change from preintervention measures in selective dorsal rhizotomy. J Neurosurg. 2007 April;106 (4Suppl):282-7 www.ncbi.nlm.nih.gov/pmc/articles/PMC2678243/odf/nihms52698.pdf
Botulinum Toxin A (BTA)
Botulinum Toxin A (BTA) is a muscle relaxant derived from the bacterium, Clostridium Botulinum. This bacteria is linked with botulism - a rare form of food poisoning - but it can provide safe, effective relief from a number of conditions when used in small, controlled doses. BTA is licensed in the UK to treat pes equinus (‘tip-toe walking’) in children with cerebral palsy. This results from spasticity in the surrounding muscles which makes it difficult, or impossible to place the foot flat on the floor. When injected into the calf muscles, BTA can relax these muscles, making walking easier and more comfortable, as well as generally improving balance and reducing the frequency of falls. The injections take effect within a few days and last until new nerve endings grow back and the affected muscles recover, usually around 12 – 16 weeks. The injections are then repeated to maintain the improvement in tone. There is no absolute limit to the number of re-injections. BTA can also be used to treat tightness in the hamstrings, hips, arms, wrists and thumbs. The main reported side-effects of BTA are mild and short-lived. These include mild cold or flu- like symptoms, temporary incontinence, mood swings/irritability, and fatigue. As yet no research is available on the possibility of adverse long-term side-effects from this treatment. Although this treatment is now becoming more common, not all NHS Boards will fund BTA. As with all medical treatments, referral should be made via your GP or consultant. Further Information The Medicines Healthcare Products Regulatory Agency produces information on BTA. Go to www.mhra.gov.uk As with any other therapy or treatment, we advise people with cerebral palsy, their carers or parents to consult their GP, consultant or health professional before starting or paying for any treatment.
Due to the individual nature of cerebral palsy, some people will benefit from specific treatments and therapies, and others will not. Assessment of individual needs is very important. This factsheet is for information purposes only and is not intended to be a recommendation. Advice Service Capability Scotland acknowledges the co-operation of SCOPE in the preparation of this fact sheet. SCOPE has more information about each procedure on individual fact sheets. For more information contact: Scope 6 Market Road London N7 9PW Telephone:0808 800 3333 website: www.scope.org.uk
Our Advice Service Advice Service Capability Scotland is a national disability advice and information service. We specialise in information on cerebral palsy. We offer:
• information on Capability Scotland services • advice on cerebral palsy • general advice on disability issues
We also have a small lending library with resources about cerebral palsy and children's books about disability. You can get in touch with us by calling, e-mailing, dropping in or writing a letter.
Advice Service Capability Scotland 11 Ellersly Road Edinburgh Tel: 0131 313 5510 Textphone: 0131 346 2529 Fax: 0131 346 7864 Email: [email protected] Web: www.capability-scotland.org.uk
This factsheet can be made available in other formats e.g. tape, large print.
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