Pharmacological and Surgical Procedures for the Treatment of Spasticity

Pharmacological and Surgical Procedures for the Treatment of Spasticity Luigi Piccinini M.D., PM&RScientific Institute Medea Bosisio Parini (LC) Italy Spasticity = pathological factorSpasticity = tool for functionSpasticity + Muscle Weakness Spasticity Reduction vs FunctionMay the force be with you (Starwars)Consider muscle strength and weakness (Piccinini)Aims of TreatmentPain reductionFunctional improvementsFacilitate use of orthosisPrevent secondary problems (muscle & bone deformities) (Early Treatment)Facilitate nursing and caring

Treatment OptionsReversibleNot reversibileGeneralFocalOral drugsITBSDRBTXSurgeryOral DrugsOral DrugsDiffused spasticityMild/moderate SpasticityToo young for other optionsSide EffectsSedationSleepinessIncreased sialorrheaExcessive hypotoniaHypotension

Baclofen (Lioresal)5 mgs/dayIncrease dosage of 5 mgs each 3-4 daysMax dosage: ???Questions?Botulinum ToxinBotulinum Toxin

Botulinum ToxinIdentify functional problemMeasure itInterventionOutcome measurementMaintain improvementBotulinum ToxinSafeNo anaphylactic reactions reportedAvoid use during pregnancyBotulinum ToxinBotoxDysportXeomin

Botulinum Toxin Dilution1 cc2 cc5 cc.Reduced or increased diffusionPrimary Non- RespondersMuscle fixed contracturesSubclinic previous botulismUSA Army immunizationSecondary Non-RespondersAntibodies in 5-10% ptsAdverse Events BoNtA Placebo> Falls9,3%3%Pain2,3%/Local weakness2,3%/General weakness 1%/Therapeutical effectBegins in 3-4 daysMax effect: 2-3 weeksDuration: 3-6 months

Adapted from: dePaiva et al. PNAS 1999, 96:320012345ActionRepeat treatmentSame muscles: 3 monthsDifferent muscles: 1 monthUntilMuscle fixed contractureAntibodiesInjection TechniquesFree?EMG guided?CT guided?US guided ?SedationMidazolam?EMLA?Spray Ice????Combined TherapiesBoNtA + PTBoNtA + orthosisBoNtA + casting /serial castingCasting / Serial Casting1 week after injectionRemove after 2 weeksPossible re-casting with increased dorsiflexionAfter removing, orthosis + PTResults Oxygen Consumption

HR

Endurance

Improvement of kinetic and kinematic parametersQuestions?Intrathecal Baclofen Intrathecal Baclofen

ITB AdvantagesReduced side effectsReduced effective dose compared to oral drugTelemetric programmingITB: EffectsImprovement of ADLsImproved compliance for PTReduce painSleep improvingITB ManagementBolus testGood response pump implantation Progressive dose increase until optimal effectEffect monitoringRefill ITB Pump Implantation

ITB Pump Programming

ITB AdvantagesHigh concentration in CSFReduced side effectsReduced spasticity only during the dayIncreased walking abilityIncreased compliance during PTReduced painReversibilityITB DisadvantagesSurgeryManagement difficultyPeriodic surgeryComplicationsRelationship Orthopaedic Issues/SpasticityTreatmentGive priority to primary problemsCorrect later orthopaedic deformitiesYou could avoid orthopaedic surgery

Post- SurgeryRehabilitation CenterProgressive increase of drug flow (20%/day)Complications monitoringPostural assessmentEvaluation for assistive devices and/or orthosisEncourage the achievement of new motor pattern

ComplicationsInfections removeCatheter kinking XRay surgeryCatheter collapse XRay surgeryLeaking Removal Management Gradual flow reduction (20%/day)Oral drugsPump switch-off / pump removal

Questions?

What about the other options?Rhyzotomy

No experience in HSP (only CP)Not reversibleOrthopaedic SurgeryNot specific for spasticitySecondary problemsAims of TreatmentRule # 1: choose THAT treatment for THAT spasticity in THAT patientGracias!luigi.piccinini@bp.lnf.it