1. How will you grade the spasticity of the patient?

2. Spasticity or muscular hypertonicity is a - disorder of the central nervous system (CNS) in which certain muscles continually receive a message to tighten and contract. -The nerves leading to those muscles, unable to regulate themselves (which would provide for normal muscle tone), permanently and continually "over-fire" these commands to tighten and contract. - This causes stiffness or tightness of the muscles and interferes with gait and movement, and sometimes speech.

3. Modified Ashworth Scale 0 No increase in muscle tone 1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the part is moved in flexion or extension/abduction or adduction, etc. 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM 2 marked increase in muscle tone through most of the ROM, but the affected part is easily moved 3 Considerable increase in muscle tone, passive movement is difficult 4 Affected part is rigid in flexion or extension (abduction or adduction, etc.)

4. Goals of spasticity management To improve function related to the activities of daily living, mobility, the ease of care by caregivers, sleep, cosmesis, and overall functional independence To prevent orthopedic deformity, the development of pressure areas, and the need for corrective surgery To reduce pain To allow the stretching of shortened muscles, the strengthening of antagonistic muscles, and the appropriate orthotic fit

5. Considerations that impact treatment Duration of spasticity and the likely duration of therapy Severity of spasticity Location of spasticity Success of prior interventions Current functional status and future goals Underlying diagnosis and comorbidities Ability to comply with treatment and therapy Availability of support/caregivers and follow-up therapy

6. treatment options Physical and occupational therapy Speech and language therapy Orthoses Casting Botulinum toxin or phenol injections Intrathecal baclofen pump implantation Orthopaedic surgery SDR surgery Oral medications

7. Physical, Occupational and Speech Therapy Physical and occupational therapy are the mainstays of treating children with cerebral palsy and other brain injuries. Therapists provide range-of-motion exercises to prevent contractures. The exercises include moving joints to maintain or improve flexibility, stretching to maintain muscle length, strengthening, and performing functional movements. Therapy also helps maximize the impact of other treatments. Speech/language pathologists assess speech and swallowing problems and work with patients to improve their language and other skills.

8. Orthoses Orthoses can help to compensate for weakness and instability. Although they typically don’t reduce spasticity, they may help prevent complications of spasticity (such as contractures) or abnormal joint positions. Ankle-foot orthoses have been known to decrease clonus at the ankle as measured by a computerized gait analysis.

9. Botulinum Toxin and Phenol Injections Neurolytic blocks (using botulinum toxin or phenol) can focally reduce hypertonicity. The blocks can be used in children of any age. The blocks often control spasticity and its complications until more aggressive treatments are appropriate. The blocks can be used indefinitely if continued functional improvements are seen.

10. Oral Medications Oral medications are a systemic, rather than focal, treatment for spasticity in children. Oral medications commonly used in children are baclofen, diazepam, dantrolene and tizanidine.

11. Surgery Intrathecal Baclofen Pump Implantation – baclofen is delivered intrathecally by a catheter attached to a subcutaneously implanted computerized pump (spasticity can be markedly reduced) – The pump needs refilling every one to three months and replacing when the battery loses power (usually after five to seven years)

12. Orthopaedic Surgery used to help correct the secondary problems that occur with growth in the face of spastic muscles and poor motion control. Those problems include muscle contractures and bony deformities.

13. SDR Surgery reduces spasticity, primarily in the trunk and legs. Surgeons identify dorsal or sensory roots at the L1 to S1 or S2 levels, then divide them into rootlets. The rootlets are then stimulated, and the resulting motor or reflex responses are monitored by electromyography and on clinical exam. If an abnormal response is seen, the rootlet is cut. The percentage of rootlets cut varies among patients, depending on their response to stimulation, but typically it’s between 25 and 45 percent.