Spasticity management guideline

• 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

24hr Postural Management 

• Consider use of upper and/or lower limb orthoses in reduced joint ranges e.g. ankle foot orthoses, resting wrist hand orthoses, thumb abduction splints
• Consider use of a standing frame, seating system and sleep system for non-ambulant children GMFCS IV-V or equivalent (see Postural Management Guidance)
• Consider providing a Postural Management Passport for parents/carers and the child/young person’s nursery or school (see Postural Management Passport template)

Active Therapy Programme  

• Physical therapy should be 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

Medical Treatment

• 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 (see BNF for Children)
• If inadequate response review adequacy of other stage 1 interventions and consider other sources of discomfort
• Refer to Paediatric Complex Motor Disorders service if lack of response to stage 1 treatments

Referral to Paediatric Neurology Complex Motor Disorders (CMD) Service*

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

Referral to Paediatric CMD 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 botulinum toxin treatment may require an adapted therapy programme and/or review of orthoses following treatment

*RHC Complex Motor Disorders & Botulinum toxin service referral form

Referral to Paediatric 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

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 bilateral lower limb spasticity due to periventricular leukomalacia (PVL) - see SDR Scotland Service Pathway for full details of clinical criteria, referral pathway and referral forms.