Spasticity management guideline

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Objectives

Goals for the management of spasticity in children

Scope

Children with spasticity

Audience

Mainly the paediatric neurology team, but this may be of help to others members of the multidisciplinary team caring for children with spasticity.

Goals of spasticity management
  • To aid posture management
  • To improve ease of care
  • To reduce spasticity related pain
  • To improve sleep
  • To improve motor function
  • To prevent or slow development of contractures and joint deformities
Child identified with cerebral palsy
  • Use standard assessment proforma & document lead clinician, topology and aetiology
  • Document joint ranges, modified Tardieu scale, GMFCS and MACS level
  • Refer to Physiotherapy, Occupational Therapy and Orthotics and consider referral to Speech therapy and Westmarc mobility services and need for home adaptations as appropriate
  • Hip surveillance - follow CPIPS pathway from age 2 years
  • Verify GMFCS level at 3 and 5 years of age
  • Routine review 6 to 12 monthly or more frequently if clinically indicated 
Stage 1

24hr Postural Management

  • Consider use of orthoses in reduced joint ranges
  • If upper limb involvement request OT and/or Orthotic review for thumb, wrist hand orthoses or elbow gaiters
  • Consider use of a standing frame, seating system and sleep system for children GMFCS IV-V
    *See 24hr Postural Management Guideline 2013 for further guidance [Staffnet link]

Anti-spasticity medication

  • Consider in order to relieve pain or muscle spasms, to aid posture management, to improve ease of care and/or to improve motor function
  • First line: Baclofen or Diazepam. Start at low dose and increase slowly to optimum therapeutic effect
  • If inadequate response review adequacy of other stage 1 interventions and consider other sources of discomfort
  • Refer to CMD service if lack of response
    to stage 1 and/or stage 2 treatments

Active Therapy Programme

  • Physical therapy should tailored to the child or young person’s individual needs and aimed at specific goals e.g. enhancing motor function, ability to participate in everyday activities and/or preventing pain or contractures
  • Progressive muscle strengthening can be used to improve function
  • Bimanual or constraint therapy may be considered in hemiplegia

 

Stage 2

Referral to Paediatric Botulinum Toxin Service

  • Indications: focal dynamic spasticity and/or dystonia which impacts on
    function, affects care-giving, reduces joint ranges, causes pain and/or
    reduces tolerance of orthoses.
  • Consider referral to CMD Upper Limb Clinic if significant thumb, wrist or elbow spasticity
  • Children who are suitable for BTx-A treatment may require an adapted therapy programme following treatment

Referral to Orthopaedic Service

  • Indications: reduced joint ranges (see CPIPS
    guidance); increasing difficulty with orthoses, seating or use of standing or walking equipment; presence of scoliosis; foot deformities; hip migration index >40% on
    pelvic x-ray
  • Botulinum toxin treatment, serial casting or surgery may be considered
  • Gait Analysis may be used to assess ambulant children with significant gait abnormalities to inform management
  • Children with clinically significant scoliosis will be referred to the National Paediatric Spinal Service.

Referral to CMD Service

  • Indications: lack of response to stage 1 treatments and to identify most
    appropriate treatment options
  • Consider in children with dyskinesia / dystonia if there is diagnostic
    uncertainty
Stage 3

Intrathecal Baclofen (ITB)

  • Refer to CMD service for consideration of ITB if significant generalised spasticity and/or dystonia in children GMFCS IV or V with inadequate response or intolerance to oral medications

Selective Dorsal Rhizotomy

  • Indications: children usually aged 5- 10 years with spastic diplegia due to PVL - see SDR Scotland Service Pathway for full details of clinical criteria, referral pathway and referral forms
References

Spasticity in children and young people with non-progressive brain disorders: NICE guideline July 2012. 

Guidance on Good Practice for the provision of 24 Hour Postural Management in Children and Young People. NHSGG&C Group of Allied Health Professionals, October 2013 [Staffnet link]

Cerebral Palsy Integrated Pathway Scotland (CPIPS)

Guidance for the Management of Ambulant Children with Neurological Conditions including Orthopaedic Single Event Multilevel Surgery (SEMLS) – Pathways and Protocols. NHSGGC 2011 revised 2014. [Staffnet link]

Selective Dorsal Rhizotomy (SDR) Scotland Service Pathway Review date: March 2020

Editorial Information

Last reviewed: 09 March 2018

Next review: 01 April 2020

Author(s): Valerie Orr

Version: 3