ITB Therapy: Role of the Interdisciplinary Team

1
Patient Management
2
Program Objectives

• Define spasticity, related anatomy, and current
  understanding of the pathophysiology of
  spasticity and other movement disorders.
• Describe the benefits and detriments of
  spasticity and how they relate to goal setting.
• Describe patient examination and evaluation,
  including the use of appropriate outcome
  measures, and related rehab interventions.
• List the indications, risks, and benefits of
  current treatment options.
• Discuss the role of the interdisciplinary team in
  the assessment and treatment of spasticity.

3
Spasticity (Lance, 1980)

• Motor disorder
• Velocity dependent increase in tonic stretch
  reflexes
• Hyperexcitability of the stretch reflex
• Exaggerated tendon jerks
• One component of the upper motor neuron syndrome
• Altered activity patterns of motor units
  occurring in response to sensory and central
  command signals which lead to co-contractions,
  mass movements, and abnormal postural control
  (Wiesendanger, 1991)

4
Upper Motor Neuron Syndrome (UMNS)

• Positive Signs
• Spasticity
• Rigidity
• Hyperreflexia
• Primitive reflexes
• Clonus

• Negative Signs
• Lack of strength
• Lack of motor control
• Lack of coordination

(Young, 1989 Young, 1997)
5
Pathophysiology of Spasticity

• Proposed Theories
• 1. Imbalance between excitatory and inhibitory
  impulses to the alpha motor neuron
• --Due to lack of descending inhibitory input to
  
• the alpha motor neuron

6
Pathophysiology of Spasticity

• 2. Descending pathways also influence Renshaw
  cells (neurons located in ventral horn) which
  suppress repeated firing of alpha motor neurons
• --lesion decreases activity of Renshaw cells
  
• reduce their inhibitory activity
• --this results in rapid, repeated firing of
  alpha
• motor neurons from repetitive stretch
  reflexes
• triggered by voluntary or passive stretch of
  
• muscle.

7
Pathophysiology of Spasticity

• Descending pathways also inhibit Golgi
  
• Tendon Organ (GTO)
• --lesion results in lack of inhibition of GTO
• excitation of stretch reflex

8
Range of Muscle Tone
Normal Range ofMuscle Tone
Flaccidity
Hypotonia
Rigidity
Hypertonia
9
Involuntary Movement Disorders

• Dystonia Abnormal posturing, twisting, or
  repetitive movements
• Chorea Irregular dance-like movements
• Athetosis Writhing, distal movements
• Choreoathetosis Combination of both chorea and
  athetosis
• Ataxia Flailing movements, wide-based gait

10
Contracture

• The difference between the joint angle at which
  extreme resistance to passive movement occurs and
  normal end-range of motion.

(Olney Wright, 1994)
11
Contracture

• Spasticity involves increased muscle activity
  from the agonist muscle group that is not
  balanced by its antagonist
• Results in persistent, abnormal joint positions
• Other factors that influence joint mobility
• Musculoskeletal growth in CP
• Arthritis (osteo and rheumatoid)
• Previous injuries to joints or soft tissue
• Previous orthopedic surgeries
• Heterotopic ossification

12
Possible Advantages of Spasticity

• Maintains muscle bulk
• Helps support circulatory function
• May prevent formation of deep vein thrombosis
• May assist in activities of daily living
• May assist with postural control

13
Consequences of Spasticity

• May interfere with mobility, exercise, joint
  range of motion
• May interfere with activities of daily living
• May cause pain and sleep disturbances
• Can make patient care more difficult

14
Considerations

• Spasticity waxes and wanes
• Dynamic vs static tone
• Multiple muscle groups may contribute to joint
  deformity
• Patient perception

15
Clinical Challenge

• "Spasticity is more difficult to characterize
  than to recognize and STILL MORE difficult to
  quantify".
• (Katz Rymer, 1989)

16
The Therapist Role in Spasticity Management

• Identify, evaluate, and educate the patient
• Guide the patient in setting goals
• Provide rehabilitation interventions that
• Decrease the influence of the positive signs
• Improve the negative signs
• Facilitate newer rehabilitation techniques
• Provide feedback and consultation to rest of
  spasticity-management team

17
Treatment Options for Patients with Spasticity
Patient
IntrathecalBaclofen (ITB) Therapy
Oral Medications
Rehabilitation Therapy
Orthopedic Surgery
Injection Therapy
Neurosurgery
18
Oral Medications

• Most common
• Baclofen (Lioresal)
• Diazepam (Valium)
• Tizanidine (Zanaflex)
• Dantrolene sodium (Dantrium)

19
Site of Action for Oral Medications

• Drug
• Baclofen
• Diazepam
• Tizanidine
• Dantrolene sodium

• Site of action
• Central Nervous System
• Central Nervous System
• Central Nervous System
• Peripheral muscle

20
Oral Medications Considerations

• Decrease positive signs
• Spasticity, Dystonia (multi-segmental)
• Spasms
• Improve negative signs
• Lack of Motor Control (use rehab to address)
• Consider other negative signs
• Lack of Strength (consider whether decreasing
  hypertonia would be detrimental to posture and
  function)

21
Oral Medications

• Advantages
• Non-invasive, not permanent
• Effective management for some patients
• Disadvantages
• Difficult to achieve a steady state
• Following a schedule may be difficult
• Side effects drowsiness, hypotonia, and weakness
  may limit effectiveness

22
Injection Therapy

• Anesthetic / Diagnostic Nerve Blocks
• Procaine
• Lidocaine
• Neurolytic Nerve Blocks
• Ethanol
• Phenol
• Botulinum Toxin

23
Botulinum Toxin

• Clostridium botulinum injected into the muscle
• Interferes with release of acetylcholine at the
  neuromuscular junction
• No systemic effect
• May be administered without anesthesia
• EMG guidance for small muscles
• Results typically last 3-6 months

24
NMJ
Purves D, Augustine GJ, Fitzpatrick D, Katz LC,
LaMantia A-S, McNamara JO, Williams SM
Neuroscience. Sunderland, MA Sinauer Associates.
2001 Pg. 113-114
25
NMJ Proteins
Purves D, Augustine GJ, Fitzpatrick D, Katz LC,
LaMantia A-S, McNamara JO, Williams SM
Neuroscience. Sunderland, MA Sinauer Associates.
2001 Pg. 113-114
26
Botox Effect on NMJ
Purves D, Augustine GJ, Fitzpatrick D, Katz LC,
LaMantia A-S, McNamara JO, Williams SM
Neuroscience. Sunderland, MA Sinauer Associates.
2001 Pg. 113-114
27
Injection Therapy Considerations

• Decrease positive signs
• Focal spasticity or dystonia
• Contracture
• Improve negative signs
• Lack of Motor Control (use rehab to address)
• Lack of Strength (use rehab to address)
• opportunity to work on strength and better
  alignment
• Consider other negative signs
• Lack of Strength (consider whether decreasing
  hypertonia would be detrimental to posture and
  function)

28
Injections

• Advantages
• Not permanent
• Evidence to support efficacy in reducing
  spasticity and improving function
• Effects are localized - not systemic
• Disadvantages
• Not permanent - may need to repeat injections
• Ethanol and Phenol require greater skill to
  inject, increased risk of paresthesias,
  dysesthesias
• Botulinum toxin more expensive than other
  injections, may develop antibodies

29
Why Botox Wears Off

• Sprouting

Courtesy of Medtronic ITB
30
Intrathecal Baclofen (ITB) Therapy

• Courtesy of Medtronic ITB

31
Intrathecal Delivery of Baclofen

• Acts as GABAb receptor agonist
• GABA (gamma-amino butyric acid) is an inhibitory
  CNS neurotransmitter
• Two receptor types (GABAa and GABAb)
• Mechanism of action is probably presynaptic
  inhibition
• Inhibits release of calcium into presynaptic
  terminals
• Thereby impedes release of excitatory
  neurotransmitters
• Baclofen is delivered directly into CSF in
  intrathecal space

32
Why Intrathecal vs. Oral?

• Intrathecal
• Lower doses than those required with oral
  administration
• Potentially fewer systemic side effects
• Oral
• Low blood/brain barrier penetration, with high
  systemic absorption and low CNS absorption
• Lack of preferential spinal cord distribution
• Adverse effects, such as drowsiness, for some
  patients

33
Pharmacokinetics of Baclofen

• Intrathecal
• 600 mcg/day dose 1.24 mcg/mL IT lumbar
  concentration
• Lumbar to cervical concentration is 41 with
  lumbar catheter tip placement
• Therapeutic dose is 1/100 of oral
• Oral
• 60 mg dose 0.024 mcg/mL IT lumbar concentration
• Half-life 3-4 hours

(Knutsson et al, 1974 Kroin Penn, 1991)
34
SynchroMed Infusion System Components

• Pump
• infuses drug at programmed rate
• Catheter
• delivers drug to theintrathecal (subarachnoid)
  space of the spinal cord
• Programmer
• allows for precise dosing
• easily adjustable dosing

Courtesy of Medtronic SynchroMed EL Infusion
System
35
Indications for ITB Therapy

• Patients must demonstrate a positive response to
  the screening test
• Patients with spasticity of spinal origin
• unresponsive to oral antispasmodics
• and/or experience unacceptable side effects at
  effective doses of oral baclofen
• Patients with spasticity of cerebral origin must
  be one year post brain injury to be considered
  for ITB Therapy

36
ITB Therapy Process

• Stage 1 Patient Selection
• Stage 2 Screening Test
• Stage 3 Implant
• Stage 4 Maintenance, Follow-up, Rehab

37
Screening Test Flow Chart
Bolus 50 mcg
-

24 hrs after Bolus 75 mcg
-

24 hrs after Bolus 100 mcg

Positive Response Implant Negative
Response No Implant
-
-

Not a Candidate
Intrathecal Baclofen Therapy Clinical Reference
Guide for Spasticity Management, Medtronic, Inc.
38
Therapy Examination During the Screening Test

• Typically assess at 2 and 4 hours post bolus
• Ashworth or Modified Ashworth Scales(AS or MAS)
• Passive/Active Range of Motion(PROM / AROM)
• Observe movement patterns
• Spasm Scale
• Pain Scale

39
Therapist Role Post-Implant

• Determine appropriate therapy venue
• Propose treatment plan
• Provide input regarding dosing

40
Potential Risks of ITB Therapy

• Common side effects
• Hypotonia
• Somnolence
• Nausea/vomiting
• Headache
• Dizziness
• Paresthesias
• Catheter and procedural complications may occur
• Overdose (rare)
• Withdrawal

41
Baclofen Overdose

• Symptoms
• Drowsiness
• Lightheadedness
• Dizziness
• Somnolence
• Respiratory depression
• Seizures
• Rostral progression of hypotonia
• Loss of consciousness (possible progression to
  coma)
• Take patient to emergency department!

42
Baclofen Withdrawal

• Symptoms
• Increased spasticity
• Itching without rash
• Tingling, paresthesias, skin "crawling"
• Hyperthermia
• Headache
• Hypotension
• Seizures
• Hallucinations
• Altered mental status
• Autonomic dysreflexia medical emergency

43
ITB Therapy Considerations

• Decrease positive signs during screening test
• Spasticity

• Improve negative signs
• Lack of Motor Control (use rehab to address)
• Consider other negative signs
• Lack of Strength (consider whether decreasing
• hypertonia would be detrimental to posture and
  function)

44
ITB Therapy Considerations

• Positive signs - ITB Therapy will not change
  these signs
• Intrinsic muscle properties
• Contracture
• Negative signs - will need rehab to see changes
• Lack of Strength
• Lack of Balance

45
Efficacy of ITB Therapy inAdults and Children

• Positive responses to screening trials
• 86 cerebral origin
• 97 spinal cord origin
• Upper and lower extremity effects noted
• Improvements for patients with functional goals
  for patients with goals of improving comfort and
  ease of care

(Albright et al, 1991 Albright et al, 1995 Penn
et al, 1989 Medtronic data on file)
46
ITB Therapy

• Advantages
• Reversible
• Non-invasive dose adjustments
• Potential for fewer side effects than oral drugs
• Evidence to support efficacy in reducing
  spasticity
• May improve function, comfort and care
• Disadvantages
• Complications infection, catheter problems,
  overdose, baclofen withdrawal
• Refills approximately every 3 months
• Cost

47
Neurosurgical Treatments

• Neurectomy
• Myelotomy
• Anterior Rhizotomy
• Selective Dorsal Rhizotomy
• Cordectomy
• Thalamotomy

(Simpson, 1995)
48
Selective Dorsal Rhizotomy (SDR)

• Dorsal sensory nerve roots are severed
• Each rootlet within root is stimulated
• Abnormally-responding rootlets are severed
• Often performed on children between ages of 7 and
  10 years
• Usually involves 6-12 months of intensive therapy
  post-operatively if improved function is goal
• Complications include possible sensory loss

(Abbott et al, 1993 Van de Wiele et al, 1996)
49
Selective Dorsal Rhizotomy (SDR)

• Antonio R. Prats, M.D., F.A.C.S., Miami, Florida

50
SDR Considerations

• Decrease positive signs
• Spasticity (multi-segmental)
• Improve negative signs
• Lack of Motor Control (use rehab to address)
• Consider other negative signs
• Lack of Strength (consider whether decreasing
  hypertonia will be detrimental to posture and
  function)

(McLaughlin et al, 1998 Steinbok et al, 1997
Wright et al, 1998)
51
SDR

• Advantages
• Permanent one-time procedure
• Evidence for efficacy in reducing spasticity and
  improving function in children with spastic
  diplegia
• Disadvantages
• Permanent may need spasticity
• Potential adverse effects spinal, sensory
• Not effective for dystonia

52
Orthopedic Surgery

• Soft-tissue operations
• lengthenings
• releases
• tendon transfers
• Bony operations
• osteotomies
• fusions

53
Orthopedic Surgery Considerations

• Decrease positive signs
• Contracture
• Abnormal Bony Alignment
• Improve negative signs
• Lack of Motor Control (may improve with rehab)
• Lack of Strength (may improve with better
  biomechanical alignment, may require rehab)
• Lack of Balance (may improve if better base of
  support)

54
Orthopedic Surgery

• Advantages
• Effects usually last a few years
• Disadvantages
• Anesthesia risks
• Non-weightbearing after bony procedures
• Risk of weakness, decreased function

55
Interdisciplinary ApproachTreatment Team Members
56
Rehabilitation

• Advantages
• Noninvasive
• Active involvement of the patient and/or family
• Emphasis on functional gains
• Disadvantages
• Casting, orthoses, positioning skin integrity
  at risk
• Cost of treatments, equipment
• Requires patient motivation participation for
  functional gains, motor learning

57
Elements of Patient Management for Optimal
Outcomes

• Guide to Physical Therapist Practice

58
Elements of Patient Management
Diagnosis
Evaluation
Prognosis
Outcomes
Examination
Intervention
59
Patient Examination

• Patient history
• Psychsocial factors
• Tests and measures

60
Patient History

• Focal or generalized tone
• Evolution of spasticity
• History of intervention
• Past medical history
• Comorbidities
• Chief complaint
• Patients/caregiver level of understanding

61
Psychosocial Factors

• Coping strategies/parenting styles
• Learning styles
• Cognition
• Family/community support
• Funding sources

62
Tests and Measures

• Muscle Performance
• Range of Motion
• Integumentary Integrity
• Pain
• Orthotic, Protective, and Supportive Devices
• Fatigue/Cardiovascular Endurance
• Posture
• Reflex Integrity
• Neuromotor Development and Sensory Integration
• Self-care and Home Management

63
Tests and Measuresfor Muscle Performance

• Static and dynamic muscle tone
• Muscle strength and selective motor control
• Function

64
Static Muscle Tone

• Ashworth and Modified Ashworth scale
• Tardieu scale
• Spasm Frequency scale
• EMG/ H Reflex

65
Modified Ashworth Scale
(Bohannon Smith, 1987)
66
Modified Tardieu Scale (Boyd, 1999)

• Consistent velocity stretch of muscle
• Standard positions for specific muscles
• Note point of resistance to maximal velocity
  stretch (R1)
• Note amount of muscle contracture or muscle
  length (R2)
• Relationship between R2-R1

67
Spasm ScaleSpasm Frequency
Penn, Savoy, New England Journal of Medicine,
1989, 3201517-1521.
68
Dynamic Muscle Tone

• Observation of Movement Patterns
• Equinus gait
• Scissor gait
• Upper extremity flexion/adduction
• Mass movement postures
• Observation Tips
• Try observing with and without orthoses or
  ambulation aids
• Video taping can be very helpful

69
Additional Examination Considerations

• Assistive devices utilized
• Seating system
• Positioning
• Functional tasks
• Status of oral medications

70
Typical Upper Extremity

• Shoulder internal rotation
• Elbow flexion
• Forearm pronation
• Wrist/ Fingers flexion
• Thumb in palm

71
Typical Lower Extremity Postures

• Hip Knee Extended
• Ankle Plantarflexed
• Foot/ ankle inverted
• OR
• Hip Knee flexed
• Ankle Plantarflexed

72
Consider the Positive Signs

• Is there
• Moderate to severe spasticity?
• Static or dynamic spasticity?
• Generalized or focal spasticity?
• What are the effects on
• Function?
• Comfort?
• Care?
• Safety?
• Is intervention directed at these signs warranted?

73
Possible Advantages of Spasticity

• Maintains muscle bulk and tone
• Helps support circulatory function
• May assist in transfers and ambulation
• May assist in activities of daily living

74
Consider the Negative Signs

• Is there a lack of
• Strength?
• Motor control?
• Coordination?
• Balance and posture?
• Endurance?
• What are the effects on
• Function?
• Comfort?
• Care?
• Safety?
• Is intervention directed at these signs warranted?

75
Consequences of Spasticity

• May interfere with
• ADLs dressing and hygiene
• Mobility rolling, sit ? supine, transfers,
  ambulation
• Exercise
• Joint range of motion
• Coordination of movement
• Ability to move ? effort
• Tolerance of orthotics/ splints
• Skin integrity
• Ability to sleep/ rest
• Feeding and speech
• Patient Care
• Driving

76
Clinical Evaluation and Patients Perspective

• Most importantly,
• Does spasticity interfere with function, care,
  or comfort?

77
Is Spasticity a Problem?Goals of Spasticity
Management

• Decrease spasticity
• Improve functional ability and independence
• Decrease pain associated with spasticity
• Prevent/ limit contractures
• Improve mobility/ ambulation
• Facilitate ADLs/ hygiene
• Save caregiver time effort

78
Gait Assessment

• Foot clearance with swing
• Foot position at late swing
• Step length
• Leg position in stance
• Amount of effort required to ambulate

79
Abnormal Gait in Spastic Diplegia

• Gait is delayed and requires great effort
• Adducted with IR of Hip
• Increased knee flexion
• Forefoot strike
• Early heel rise
• Excessive lumbar lordosis
• Circumducts or excessively flexes hip-knee to
  advance leg

80
Abnormal Gait with Spastic Hemiplegia

• Toe strike
• Knee hyperextension
• Posturing of ipsilateral upper extremity
• Trunk lean

81
Abnormal Gait with Spastic Hemiplegia

• To advance LE
• Hip hiking
• Trunk lean to opposite side
• Circumduction
• Excessive Hip Knee Flexion
• Vaulting

82
Abnormal Gait with Spastic Hemiplegia
83
Functional PrognosisPrimarily Ambulatory

• Balance and safety
• Endurance and energy conservation
• Gait pattern
• Additional areas where skill level could improve
• Driving
• Athletic performance

84
Functional PrognosisPrimarily Wheelchair Use

• Transfers, mobility, and safety
• Position and function in wheelchair
• Additional goals could include
• Fine motor control switch access
• Speech
• Feeding oral motor skills
• Preparation for other interventions

85
Rehabilitation Therapy

• EMG biofeedback
• Electrical stimulation
• Vibration of the antagonist
• Constraint-induced
• Movement Therapy
• Selective Strengthening of Antagonist
• Aquatic Therapy
• Handling/ Inhibitory Pressure

• Stretching
• Casting
• Orthoses
• Weight bearing
• Positioning Seating
• -Podus Boots
• -Versaform
• -Splints/ Bivalves
• -Aircast
• Practice functional tasks
• Sensory Integration

86
Focus on.

• Elongation of shortened tissues
• Strengthening
• Improving motor control
• Address underlying weakness

87
Treatment Approaches

• NDT
• Normalize muscle tone/ posture
• Inhibit reflexes
• Facilitate normal movement
• Use of handling/ facilitation techniques
• Motor Learning
• Practice functional tasks

88
Treatment Approaches

• Therapeutic Exercise
• Stretching and ROM
• Active assistive, active, resistive exercise
• E-stim. (fatigue OR strengthen)
• Weight bearing
• Aquatic therapy
• Rhythmic rotation
• Contract-Relax
• Handling/ key points of control Inhibitory
  pressure
• Ice
• Warmth
• Biofeedback

89
Treatment Approaches

• Functional Training
• gait, ADLs, mobility, school-based (to enhance
  education)
• Consider equipment and environmental adaptations
  to maximize function

90
Other Treatment Approaches

• Restraint-induced
• Play
• FES
• School based vs. medically based
• Not just one approachblending of whats
  effective for
• patient

91
Positioning

• Positioning (in bed, w/c, and other)
• Podus boots
• Versaform
• Splints
• Aircast

92
Positioning
93
Casting/ Splinting

• Inhibitory Casting
• Serial Casting
• Bivalve Splints
• AFOs
• SMOs
• Upper Extremity/ Hand Splints

94
Inhibitory Casting

• Theoretical Principles
• Static positioning interrupts stretch reflex
• Circumferential casting provides neutral warmth
  and constant pressure
• Decreases variability of cutaneous sensory input
  which can elicit stretch reflex
• Promotes changes in muscle tendon length and
  sarcomere distribution

95
Inhibitory Casting

• Indications
• Elevated muscle tone present
• Full/ functional ROM present
• Little isolated, active (non-synergistic)
  movement is present
• Holding or posturing is observed

96
Inhibitory Casting

• General Principles
• Cast in sub-maximal range
• Leave on 3-5 days
• Complete a thorough assessment after removal
• Apply new cast or bivalve ASAP
• Use with abnormal movement

97
Serial Casting

• Theoretical Principles
• Low-force, long-duration stretch produces
  residual elongation of connective tissue
• Gentle, prolonged stretch results in cell
  division
• Provides inhibitory effect

98
Serial Casting

• Indications
• Spasticity is present
• Loss of PROM is significant

99
Serial Casting

• General Principles
• Apply cast in submaximal range
• Leave on 5-10 days
• Complete thorough assessment after removal
• Casting multiple joints
• Decide what to do next (cast or splint)
• If cast again , do immediately
• If splinting, do ASAP

100
Therapist Evaluation Prior to Casting

• Cognitive status
• Sensation
• Skin integrity
• Effects of positioning and gravity
• Psychosocial issues
• Recommendation for other interventions (botox)
• Type of casting serial vs. inhibitory
• Quality of motion
• Active vs. passive
• Isolated vs. synergistic
• Do ALL prior to casting and again AFTER each cast

101
Contraindications for Casting

• Medically unstable
• Edematous areas
• Fragile skin
• Compromised circulation
• Agitation and confusion
• Impaired Sensation
• Open Wounds
• Abrasions
• Lacerations

102
Contraindications for Casting

• Multiple Extremities
• Multiple Joints
• Bony Malformations
• Subluxation
• Unhealed fracture
• HO
• Loose bodies
• Arthritis

103
Cast Padding

• Progressive Casting and Splinting for Lower
  Extremity Deformities on Children with Neuromotor
  Dysfunction- Beverly Cusick Therapy Skill
  Builders Tuscon, AR 1990 pg. 278

104
Caregiver Monitors

• Pulse and respirations
• Skin temp
• Skin color
• Pain
• Edema
• Reddened areas or blisters
• Cast condition
• Limb position

105
General Info on Casting

• Casting is usually most effective proximal ?
  distal will see some distal inhibition with
  proximal inhibition
• Need to prioritize individually per patient
  needs, medical status, and tolerance
• Heat generated in a cast may be in itself
  inhibitory for tone

106
More General Info on Casting Spasticity
Management

• Air splints are generally ineffective as means of
  inhibiting tone due to softness and inconsistent
  pressure best used for positioning during
  treatment
• Whole body positioning may be beneficial
  primitive reflex patterns and synergies need to
  be inhibited to decrease tone
• Serial casting uses same principles of
  Inhibitory, but low load, prolonged stretch
  physiologic changes (? in sarcomeres) permanent
  change in muscle length

107
Long Arm Cast

• Gillen G Burkhardt, A, Stroke Rehabilitation A
  Function-Based Approach. Mosby St. Louis, 1998

108
Drop-out Elbow Cast
Gillen G Burkhardt, A, Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis, 1998
109
Drop-out Cast

• Gillen G Burkhardt, A, Stroke Rehabilitation A
  Function-Based Approach. Mosby St. Louis, 1998

110
Hand Wrist Casts

• Gillen G Burkhardt A, Stroke Rehabilitation A
  Function-Based Approach. Mosby St. Louis, 1998

111
Hand Wrist Casts
Gillen G Burkhardt A, Stroke Rehabilitation A
Function-Based Approach. Mosby St. Louis, 1998
112
Leg Casts

• Gillen G Burkhardt A, Stroke Rehabilitation A
  Function-Based Approach. Mosby St. Louis, 1998
  

113
Casting

• Another tool in our bag
• -cost-effective vs medical
• -fairly non-invasive
• -it works!

114
Additional Roles of Therapists

• Input for selection of muscle injection/ surgical
  intervention/ medication based on functional
  picture
• Feedback to physician regarding effects of
  medical management
• Suggestions/ ideas for future management to
  maximize function
• Seek input of other team members
• Monitor patient for changes in status
• Provide inhibition facilitation techniques
  especially after casting /or medical treatments
• Serve as referral source in community
• Assist with oral motor skills

115
Reassess Equipment Needs

• Seating system
• Standing equipment
• Orthotics
• Bathroom equipment
• Assisted technology
• Augmentative communication

116
Adult Outcomes General

• Functional Independence Measure (FIM)
• Functional Assessment Measure (FAM)
• Canadian Occupational Performance Measure (COPM)
• Goal Attainment Scaling (GAS)
• Timed Up and Go (TUG)
• Pain Scales

117
Adult Outcomes General

• Barthel Index
• Observational Gait Scale (OGS)
• Sickness Impact Profile (SIP)
• SF-36 (QOL measure)
• 3-Dimensional Gait Analysis (3DGA)

118
Adult Outcomes Stroke

• Chedoke-McMaster Stroke Assessment (CMSA)
• Berg Balance Scale (BBS)
• Tinetti Balance Scale

119
Adult Outcomes MS

• Multiple Sclerosis Functional Composite (MSFC)
• Minimal Record of Disability for MS (MRDMS)
• Modified Fatigue Impact Scale (MFIS)

120
Evidence Botox

• Effective and safe to manage spasticity in
  children
• Love et al
• Desloovere et al
• Boyd and Hays
• Chambers
• Fragala
• Graham
• Houltram et al

121
Evidence Botox

• and Adults
• Hesse et al
• Pierson et al
• Yablon et al
• Simpson et al
• Graham and Rawicki

122
Evidence Casting

• Effective in improving ROM and reducing
  spasticity
• Hill
• Barnard et al
• Nash
• Mortenson and Eng
• Cottalorda et al
• Lehmkuhl et al
• Booth et al

123
Evidence Botox vs. Casting

• Houltram et al
• Flett et al
• Corry et al
• Significant improvement in tone reduction and
  gait for both groups
• Botox was preferred treatment by caregivers
• Botox lasted longer

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Evidence Botox Casting

• Booth et al both together caused faster results
  (improved gait and ROM) as compared to just
  casting
• Desloovere et al Group casted AFTER Botox
  improved more with 3DGA than group casted PRIOR
  to Botox
• Graham et al Less regression and loss of
  function if casted with Botox than if surgery

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Cases
126
Jeffrey

• 6 y/o CVA at birth/ CP Left Hemi
• OT/PT since 1y/o, 1-2X/ week
• Spasticity Left upper lower extremities
• Impaired Left sensation/ position sense
• Gait toe walker, decreased step length on right,
  circumduction to advance left leg
• Impaired balance especially in standing
• Short hamstrings poor sitting posture

127
Jeffrey

• Treatment
• Botox left finger and wrist flexors left
  plantarflexors hamstrings
• Inhibitory Casting left foot/ ankle in DF
• Inhibitory Casting left hand/ wrist in neutral
• Weight bearing
• Hands and knees
• Side-sitting
• stance
• Dynamic stretch to hamstrings and gastrocs
• Splints worn at nighttime
• Home Program long sitting while playing games,
  use of left hand,
  stretching, wrist extension and ankle DF
• Coordination balance activities

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Jeffreys Outcome

• Began walking with occasional heel strike/ flat
  foot
• Improvements with balance during gait on stairs
• Began jumping (still uses R gt L)
• Able to move ½ kneel ? stand over left leg
• Hops on left leg with help
• ? Limp (still present)
• ? speed/ started running

129
Jeffreys Outcome

• Ongoing
• lack of heel strike
• decreased push-off on left
• ? stability in Quad
• uses R gt L
• Mild limp
• Difficulty with advanced motor/ coordination
  activities

130
Jeffreys Outcome

• Opens hand fingers
• Controlled grasp release
• Can obtain neutral forearm position
• ? strength proximally
• Function uses left as assist
• Ex shoe tying
• Began walking with occasional heel strike/ flat
  foot
• Improvements with balance during gait on stairs
• Began jumping (still uses R gt L)
• Able to move ½ kneel ? stand over left leg
• Hops on left leg with help
• ? Limp (still present)
• ? speed/ started running

131
Jeffreys Outcome

• Ongoing
• Grip strength poor
• Lacks full supination
• Trunk substitution for IR and ER
• lack of heel strike
• decreased push-off on left
• ? stability in Quad
• uses R gt L
• Mild limp
• Difficulty with advanced motor/ coordination
  activities

132
Sarah

• 21y/o, TBI due to MVA
• Rancho II
• Significant Spasticity throughout extremities,
  trunk, neck
• Video

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Conclusion

• Choose the treatment or treatments that address
  the positive and negative signs interfering with
  attainment of the patient and family/caregiver
  goals, keeping in mind the psychosocial and
  medical factors.
• COMMUNICATION
• With other team members
• With Physician

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Credits

• To Edward Wright, MD and LeaAnn Brittain, ME, OTR
  who originally developed parts of this
  presentation
• To Giulianne Krug, ME, OTR for providing
  information on spasticity and benefits of
  casting.
• To Medtronics for data and information, graphics
  and formatting used within this presentation.

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References and Suggested Reading

• 10- page list of references can be viewed
  separately