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.

Children with cerebral palsy and other non-progressive neurological motor disorders often have increased muscle tone due to spasticity which impacts on their motor function, posture, comfort, quality of life and can result in musculoskeletal complications. This guideline summarises standard care approaches and the role of the Paediatric Complex Motor Disorder service as part of the network of health care for children with spasticity in NHS Greater Glasgow & Clyde.

Additional information about local care pathways and national guidance can be found on the NHS Greater Glasgow & Clyde StaffNet Cerebral Palsy Management page and by referring to the NICE guideline ‘Spasticity in under 19s: management’.

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
Stage 1

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
Stage 2

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
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 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.
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: 03 December 2020

Next review: 01 November 2023

Author(s): Valerie Orr

Version: 4