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Treating Spasticity Disorders

Team Approach Offers Optimum Care for Children

New York (Jun 25, 2009)

Staff treating child with spasticity disorder

Parents of children with spasticity disorders must often consult numerous specialists in an attempt to find the right combination of treatments to allow their child optimal function and quality of life. Frequently, the process is overwhelming and frustrating requiring multiple visits in a number of locations. The Spasticity Center at NewYork-Presbyterian Morgan Stanley Children's Hospital is providing children with spasticity individualized treatment and enhanced care as part of a newly implemented multidisciplinary approach. Calling on treatment teams comprised of pediatric neurosurgeons, pediatric neurologists, orthopedists, physical therapists, occupational therapists, nurse practitioners, social workers, and specialists in bracing, the Center offers children with these complex disorders an expanded arsenal of potential treatments – all in one location.

Spasticity results from damage to the motor pathways of the brain or spinal cord and is characterized by spasms or tightening of the muscles causing stiffness and tightness of the muscles. Spasticity can affect movement, walking and speech and can vary from mild stiffness to severe, painful muscle spasms. Spastic disorders are associated with conditions such as cerebral palsy, spastic paralysis, brain injury and multiple sclerosis.

"These children have complex needs. Multidisciplinary care permits specialists to work together to provide more comprehensive solutions to problems," says Richard C.E. Anderson, MD, Director of the Spasticity Center. "Typically, our specialists not only collaborate to determine the best approach to each patient's problem, but also offer different aspects of care that together produce an optimal outcome."

Developing the Most Effective Treatment Plan

Improving mobility and function may involve treatments that address nerves, tendons, muscles, bones, or some combination of these. In certain cases, team specialists are able to offer approaches that are not widely available. One of these procedures is selective dorsal rhizotomy (SDR), nerve surgery for symptoms related to cerebral palsy. During SDR, a surgeon cuts the skin over the lower part of the spinal cord, then finds and cuts the nerves in the cord that are causing muscle tightness in the legs.

"The procedure, guided by ultrasound, involves only a 1-inch incision at the bottom of the spinal cord," says Dr. Anderson, who performs a minimally invasive SDR by removing only one level of bone. "SDR is performed with a physical and occupational therapist in the operating room. The therapists maintain contact with target muscles in order to help identify abnormal responses when an electrical stimulus of the nerve root is generated. This allows real-time physiologic feedback that provides intraoperative guidance on which nerve rootlets to cut." Typically, the physical therapist has been working with the patient prior to the procedure and is therefore intimately acquainted with the precise muscle targets.

There is not usually just one solution for each patient. The goal of a multidisciplinary approach is to develop the most effective plan through the consensus of multiple experts. A number of innovations have been made during the past couple of decades for the treatment of spasticity, and all are considered. For example, whereas intramuscular injections of botulinum toxin type A (Botox), which provides excellent but temporary muscle relaxation, may be sufficient for some children, others may need an implantable and programmable intrathecal baclofen pump, which delivers a muscle relaxant directly into the spinal fluid and provides continuous action. A child may benefit from a tendon release to improve range of motion, but their ability to improve function may also depend on physical therapy or physical therapy in combination with pharmacologic therapy, such as Botox injections or muscle relaxants. "There are advantages and disadvantages to many of these options," explains Dr. Anderson, "and we work with children and their parents to identify an approach with which they are comfortable."

Faculty Contributing to this Article:

Richard C.E. Anderson, Director, Spasticity Center, Morgan Stanley Children's Hospital of NewYork-Presbyterian, and Assistant Professor of Neurosurgery and Pediatric Neurosurgery at Columbia University College of Physicians and Surgeons

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