Dott.ssa Caterina Delia
Physical medicine and rehabilitation (PM&R)
physician
DH Neuroriabilitazione e Attività Sportiva Adattata
OPBG-Palidoro
SPASTICITY
CLINICAL CASES
Spasticity - Clinical Cases
• Case 1
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
• Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
Introduction Clinical evaluation
OBSERVATION
- Signs of contractures, posture, hip subluxation, primitive reflexes
! PAY ATTENTION ! if noxious stimulation or discomfort can increase spasticity e.g pain
Introduction Clinical evaluation
STATIC EVALUATION
DYNAMIC EVALUATION
- Range of motion evaluation (pROM e aROM) - Trunk control sitting, posture evaluation
- Thomas test - Functions of the upper limb (reaching, grasping - Silfverskiold test AVQ)
- Hip internal rotation/Hip external rotation - Gait (with/without orthosis and aids)
- Hip abduction with kneee extended/ knee flexed
- Popliteal angle
- Pendulum Test/Ely Test
Popliteal angle
Pendulum Test
Ely Test
Silfevrskiold Test
Decision Making Process for pediatric spasticity management
No standard approach exist !
• Timing of spasticity management
-Physical therapy and rehabilitation
-Chemoneurolysis BTX after 2 years of age
-Phenol and alcohl are less popular
-Ortopedic surgery (4 yrs or older)
-Selective Dorsal Rhyzotomy (DR) for around 4-5 yrs old with dyplegia and severe spasticity
- ITB pump
• Focal spasticity versus diffuse:
If spasticity is focal, BTX is recommended. For diffuse spasticity, oral antispastic drugs or single event multilevel
chemonerolysis with BTX or Phenol alcool blocks are considered
Botulinum Toxin in the Management of Children with Cerebral Palsy
GOALS OF SPASTICITY MANAGEMENT
The evaluation is therefore based on the achievement, or otherwise, of a specific objective.
The paradigm of the GAS scale does not allow a clinical evaluation focused specifically on spasticity
It’s an indicator of the symptoms, behaviours and abilities, shared with the patient and/or the caregiver
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
Female, 4 Yrs
Brain MRI: ”Widespread signal alteration of the left hemispheric deep white matter, in particular of the semioval centers with extension in the perirolandic area of the posterior arm of the internal capsule ipsilaterally.”
Right hemiparesis, speech disorder
Rehabilitation treatment:
- 2 physiotherapy treatment per week
- 2 speech therapy per week
Case 1
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
Case 1
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
EVALUATION PRE-TREATMENT
Possible transfers on their own with orthoses (CAMO on the right leg)
Without orthosis, supinated foot flight and knee flexion with reduced activation of the tibiotarsal joint can be observed in the flight phase
After viewing the video recording and joint discussion with the dedicated motor physiotherapist, it is decided to inoculate the Semitendinosus muscle (25 UI)
Case 1
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
Ultrasound-guided focal treatment with botulinum toxin in the lower limb after walking’s video evaluation
EVALUATION POST-TREATMENT
After the treatment with botulinum toxin, it is observed a smoother gait pattern and a better coordination, with a reduction of knee’s flexion in stance phase
With regard to the orthosis, it is agreed to replace the carbon fibre bar with a less elastic one in order not to strain the ischiocrural muscles
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
Male, 15 yrs
• Rehabilitation treatment: 3 physiotherapy sessions per week + stretching performed at home Sport: swimming (during the summer)
• Schooling: First year of high school with good profit.
Perinatal distress resulting in a right hemiparesis with a spastic-dystonic pattern
Since 2019 he has been followed at our toxin clinic for focal treatment of the right upper limb
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
At rest L R pROM MAS (Modified Ashworth scale)
Shoulder - -
Elbow Extended, Pronated forearm
Flexion: +140°
Extension: 0°
Wrist Flexed 15° NN
Fingers Flexed PIP joints 80°
Thumb Flexed (IJ),in palm
Elbow extensors: 3
Pronator Teres: 2
Wrist flexors: 1
Flexion: NN
Extension: 0° PIP: 3
Flexion: NN
Extension: 0° FPL: 3
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
WHAT GOALS HAVE WE SET ?
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
WHAT GOALS HAVE WE SET ?
Decreased “stiffness” of the right upper limb with improved posture at rest and during walking (Imp 3,Diff 1)
Improved autonomy in dressing (Imp 3, Diff 2)
Improving the integration of the affected limb in activities of daily living (Imp 3, Diff 3)
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the
upper limb
TRICEPS BRACHII, 40 UI
PRONATOR TERES, 30 UI
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
FLEXOR DIGITORUM SUPERFICIALIS, 40 UI
FLEXOR POLLICIS LONGUS, 30 UI
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
GAS SCALE
Case 2
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
Ultrasound-guided focal treatment with botulinum toxin in the upper limb
THANKS FOR THE ATTENTION
Vite che aiutano la Vita
Il presente documento è stato elaborato slide da Ospedale Pediatrico Bambino Gesù
I contenuti sono strettamente riservati; è vietata la riproduzione e la divulgazione, anche solo parziale, senza il benestare scritto di Ospedale Pediatrico Bambino Gesù.
Grazie!