Patient Management

Program Objectives
• Define spasticity, related anatomy, and current
understanding of the pathophysiology of spasticity
and other movement disorders.
• Describe the benefits and detriments of spasticity
and how they relate to goal setting.
• Describe patient examination and evaluation,
including the use of appropriate outcome measures,
and related rehab interventions.
• List the indications, risks, and benefits of current
treatment options.
• Discuss the role of the interdisciplinary team in the
assessment and treatment of spasticity.
 Spasticity (Lance,
1980)
• Motor disorder
• Velocity dependent increase in tonic stretch reflexes
• Hyperexcitability of the stretch reflex
• Exaggerated tendon jerks
• One component of the upper motor neuron syndrome
• Altered activity patterns of motor units occurring in
response to sensory and central command signals which
lead to co-contractions, mass movements, and abnormal
postural control (Wiesendanger, 1991)
Upper Motor Neuron
Syndrome (UMNS)
Positive Signs Negative Signs
• Spasticity • Lack of strength
• Rigidity • Lack of motor
• Hyperreflexia control
• Primitive reflexes • Lack of
• Clonus coordination

(Young, 1989; Young,

1997)
 Pathophysiology of
Spasticity
Proposed Theories:
1. Imbalance between excitatory
and inhibitory impulses to the
alpha motor neuron
--Due to lack of descending
inhibitory input to
the alpha motor neuron
 Pathophysiology of
Spasticity
2. Descending pathways also influence Renshaw cells
(neurons located in ventral horn) which suppress repeated
firing of alpha motor neurons
--lesion decreases activity of Renshaw cells =
reduce their inhibitory activity
--this results in rapid, repeated firing of alpha
motor neurons from repetitive stretch reflexes
triggered by voluntary or passive stretch of
muscle.
 Pathophysiology of
Spasticity
3. Descending pathways also inhibit
Golgi
Tendon Organ (GTO)
--lesion results in lack of inhibition
of GTO =
excitation of stretch reflex
Range of Muscle Tone

Normal
Flaccidit Hypoton Range of Hyperto Rigidity
y ia Muscle nia
Tone
 Involuntary Movement
Disorders

Dystonia: Abnormal posturing, twisting, or

repetitive movements
Chorea: Irregular dance-like movements
Athetosis: Writhing, distal movements
Choreoathetosis: Combination of both chorea and
athetosis

Ataxia: Flailing movements, wide-based

gait
 Contracture
The difference between the joint
angle at which extreme resistance to
passive movement occurs and
normal end-range of motion.

(Olney & Wright, 1994)

 Contracture
• Spasticity involves increased muscle activity
from the agonist muscle group that is not
balanced by its antagonist
• Results in persistent, abnormal joint positions
• Other factors that influence joint mobility
– Musculoskeletal growth in CP
– Arthritis (osteo and rheumatoid)
– Previous injuries to joints or soft tissue
– Previous orthopedic surgeries
– Heterotopic ossification
Possible Advantages of
Spasticity
• Maintains muscle bulk
• Helps support circulatory
function
– May prevent formation of
deep vein thrombosis
• May assist in activities of
daily living
• May assist with postural
control
 Consequences of
Spasticity
• May interfere with mobility, exercise,
joint range of motion
• May interfere with activities of daily
living
• May cause pain and sleep
disturbances
• Can make patient care more difficult
 Considerations
• Spasticity waxes and wanes
• Dynamic vs static tone
• Multiple muscle groups may
contribute to joint deformity
• Patient perception
 Clinical Challenge
"Spasticity is more difficult to
characterize than to recognize and STILL
MORE difficult to quantify".

(Katz & Rymer, 1989)

The Therapist Role in Spasticity
Management

• Identify, evaluate, and educate the patient

• Guide the patient in setting goals
• Provide rehabilitation interventions that:
– Decrease the influence of the positive signs
– Improve the negative signs
– Facilitate newer rehabilitation techniques
• Provide feedback and consultation to rest of spasticity-
management team
Treatment Options for Patients
with Spasticity

Intrathecal
Baclofen
(ITB™)
Therapy
Rehabilitation Oral
Therapy Medications

Patient
Orthopedic Injection
Surgery Therapy

Neurosurgery
 Oral Medications
Most common:
• Baclofen (Lioresal®)
• Diazepam (Valium®)
• Tizanidine (Zanaflex®)
• Dantrolene sodium (Dantrium®)
 Site of Action for Oral
Medications
Drug Site of action

Baclofen Central Nervous

System
Diazepam Central Nervous
System
Tizanidine
Central Nervous
System
Dantrolene sodium
Peripheral: muscle
 Oral Medications:
Considerations
Decrease positive signs
• Spasticity, Dystonia (multi-segmental)
• Spasms
Improve negative signs
• Lack of Motor Control (use rehab to address)
Consider other negative signs
• Lack of Strength (consider whether decreasing
hypertonia would be detrimental to posture
and function)
 Oral Medications
Advantages
• Non-invasive, not permanent
• Effective management for some patients
Disadvantages
• Difficult to achieve a steady state
• Following a schedule may be difficult
• Side effects: drowsiness, hypotonia, and
weakness may limit effectiveness
 Injection Therapy
• Anesthetic / Diagnostic Nerve Blocks
– Procaine
– Lidocaine
• Neurolytic Nerve Blocks
– Ethanol
– Phenol
• Botulinum Toxin
 Botulinum Toxin
• Clostridium botulinum injected into the muscle
• Interferes with release of acetylcholine at the
neuromuscular junction
• No systemic effect
• May be administered without anesthesia
• EMG guidance for small muscles
• Results typically last 3-6 months
 NMJ

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114
 NMJ Proteins

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114
 Botox Effect on NMJ

Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia A-S, McNamara JO, Williams SM Neuroscience. Sunderland, MA: Sinauer Associates. 2001 Pg. 113-114
 Injection Therapy:
Considerations
Decrease positive signs
• Focal spasticity or dystonia
• Contracture
Improve negative signs
• Lack of Motor Control (use rehab to address)
• Lack of Strength (use rehab to address)
– opportunity to work on strength and better alignment
Consider other negative signs
• Lack of Strength (consider whether decreasing
hypertonia would be detrimental to posture and
function)
 Injections
Advantages
• Not permanent
• Evidence to support efficacy in reducing
spasticity and improving function
• Effects are localized - not systemic

Disadvantages
• Not permanent - may need to repeat
injections
• Ethanol and Phenol: require greater skill to
inject, increased risk of paresthesias,
dysesthesias
• Botulinum toxin: more expensive than other
injections, may develop antibodies
 Why Botox Wears Off

• Sprouting

Courtesy of
Medtronic ITB™
Intrathecal Baclofen
(ITB™) Therapy

Courtesy of Medtronic ITB™

 Intrathecal Delivery of
Baclofen
• Acts as GABAb – receptor agonist
– GABA (gamma-amino butyric acid) is an inhibitory CNS
neurotransmitter
– Two receptor types (GABAa and GABAb)
• Mechanism of action is probably presynaptic
inhibition
– Inhibits release of calcium into presynaptic terminals
– Thereby impedes release of excitatory
neurotransmitters
• Baclofen is delivered directly into CSF in
intrathecal space
 Why Intrathecal vs.
Oral?
• Intrathecal
– Lower doses than those required with oral
administration
– Potentially fewer systemic side effects
• Oral
– Low blood/brain barrier penetration, with
high systemic absorption and low CNS
absorption
– Lack of preferential spinal cord distribution
– Adverse effects, such as drowsiness, for
some patients
 Pharmacokinetics of
Baclofen
• Intrathecal
– 600 mcg/day dose: 1.24 mcg/mL IT lumbar
concentration
– Lumbar to cervical concentration is 4:1 with
lumbar catheter tip placement
– Therapeutic dose is 1/100 of oral
• Oral
– 60 mg dose: 0.024 mcg/mL IT lumbar
concentration
– Half-life 3-4 hours
(Knutsson et al, 1974; Kroin &
Penn, 1991)
 SynchroMed® Infusion System
Components

Pump
• infuses drug at programmed rate

Catheter
• delivers drug to the
intrathecal (subarachnoid)
space of the spinal cord

Programmer
• allows for precise dosing
• easily adjustable dosing

Courtesy of Medtronic: SynchroMed ® EL Infusion System

 Indications for ITB™
Therapy
• Patients must demonstrate a positive
response to the screening test
• Patients with spasticity of spinal origin:
– unresponsive to oral antispasmodics
– and/or experience unacceptable side effects
at effective doses of oral baclofen
• Patients with spasticity of cerebral origin
must be one year post brain injury to be
considered for ITB Therapy
 ITB™ Therapy Process
Stage 1: Patient Selection
Stage 2: Screening Test
Stage 3: Implant
Stage 4: Maintenance, Follow-up, & Rehab
 Screening Test Flow
Chart
Bolus: 50 mcg

+ -
24 hrs after
Bolus: 75 mcg

+ -
+ = Positive Response 24 hrs after
“Implant” Bolus: 100 mcg

- = Negative Response
+ -
“No Implant”

Intrathecal Baclofen Therapy Clinical Reference Guide for Spasticity Management, Medtronic, Inc. Not a Candidate
 Therapy Examination
During the Screening
Test
• Typically assess at 2 and 4 hours post bolus
• Ashworth or Modified Ashworth Scales
(AS or MAS)
• Passive/Active Range of Motion
(PROM / AROM)
• Observe movement patterns
• Spasm Scale
• Pain Scale
 Therapist Role Post-
Implant
• Determine appropriate therapy
venue
• Propose treatment plan
• Provide input regarding dosing
 Potential Risks of ITB™
Therapy
• Common side effects:
– Hypotonia
– Somnolence
– Nausea/vomiting
– Headache
– Dizziness
– Paresthesias
• Catheter and procedural complications
may occur
• Overdose (rare)
• Withdrawal
 Baclofen Overdose
• Symptoms
– Drowsiness
– Lightheadedness
– Dizziness
– Somnolence
– Respiratory depression
– Seizures
– Rostral progression of hypotonia
– Loss of consciousness (possible progression
to coma)
• Take patient to emergency department!
 Baclofen Withdrawal
• Symptoms
– Increased spasticity
– Itching without rash
– Tingling, paresthesias, skin "crawling"
– Hyperthermia
– Headache
– Hypotension
– Seizures
– Hallucinations
– Altered mental status
– Autonomic dysreflexia = medical
emergency
 ITB™ Therapy:
Considerations
• Decrease positive signs during
screening test
– Spasticity
•Improve negative signs
–Lackof Motor Control (use rehab to
address)
•Consider other negative signs
–Lackof Strength (consider whether
decreasing
hypertonia would be detrimental to
 ITB™ Therapy:
Considerations
• Positive signs - ITB Therapy will not
change these signs
– Intrinsic muscle properties
– Contracture

• Negative signs - will need rehab to see

changes
– Lack of Strength
– Lack of Balance
 Efficacy of ITB™ Therapy
in
Adults and Children
• Positive responses to screening trials:
– 86% cerebral origin
– 97% spinal cord origin
• Upper and lower extremity effects noted
• Improvements for patients with functional
goals & for patients with goals of improving
comfort and ease of care

(Albright et al, 1991; Albright et al,

1995; Penn et al, 1989; Medtronic data
on file)
 ITB™ Therapy
• Advantages
– Reversible
– Non-invasive dose adjustments
– Potential for fewer side effects than oral drugs
– Evidence to support efficacy in reducing spasticity
– May improve function, comfort and care
• Disadvantages
– Complications: infection, catheter problems,
overdose, baclofen withdrawal
– Refills – approximately every 3 months
– Cost
 Neurosurgical
Treatments
• Neurectomy
• Myelotomy
• Anterior Rhizotomy
• Selective Dorsal Rhizotomy
• Cordectomy
• Thalamotomy

(Simpson, 1995)
 Selective Dorsal
Rhizotomy (SDR)

• Dorsal sensory nerve roots are severed

• Each rootlet within root is stimulated
• Abnormally-responding rootlets are severed
• Often performed on children between ages of
7 and 10 years
• Usually involves 6-12 months of intensive
therapy post-operatively if improved function
is goal
• Complications include possible sensory loss

(Abbott et al, 1993; Van de Wiele et al,

Selective Dorsal
Rhizotomy (SDR)

Antonio R. Prats, M.D., F.A.C.S., Miami, Florida

 SDR: Considerations
• Decrease positive signs
– Spasticity (multi-segmental)
• Improve negative signs
– Lack of Motor Control (use rehab to
address)
• Consider other negative signs
– Lack of Strength (consider whether
decreasing hypertonia will be
detrimental to posture and function)
(McLaughlin et al, 1998; Steinbok et al, 1997;
 SDR
• Advantages
– Permanent – one-time procedure
– Evidence for efficacy in reducing spasticity
and improving function in children with
spastic diplegia

• Disadvantages
– Permanent – may need spasticity
– Potential adverse effects: spinal, sensory
– Not effective for dystonia
 Orthopedic Surgery
• Soft-tissue operations
– lengthenings
– releases
– tendon transfers

• Bony operations
– osteotomies
– fusions
 Orthopedic Surgery:
Considerations

• Decrease positive signs

– Contracture
– Abnormal Bony Alignment

• Improve negative signs

– Lack of Motor Control (may improve with
rehab)
– Lack of Strength (may improve with better
biomechanical alignment, may require
rehab)
– Lack of Balance (may improve if better base
of support)
 Orthopedic Surgery
• Advantages
– Effects usually last a few years

• Disadvantages
– Anesthesia risks
– Non-weightbearing after bony
procedures
– Risk of weakness, decreased function
 Interdisciplinary
Approach
Treatment Team Members
Family and Physiatrist
Caregiver Neurologist

Nurse
Primary Care
Social Worker
and Family
Speech
Physician
Therapist Person with
Spasticity

Orthotist Physical and

Seating Occupational
Specialist Therapists
Neurosurgeon
Orthopedist
 Rehabilitation
• Advantages
– Noninvasive
– Active involvement of the patient and/or
family
– Emphasis on functional gains

• Disadvantages
– Casting, orthoses, positioning: skin integrity
at risk
– Cost of treatments, equipment
– Requires patient motivation & participation
for functional gains, motor learning
Elements of Patient
Management for
Optimal Outcomes
Guide to Physical Therapist
Practice
Elements of Patient
Management
Diagnosis

Evaluation Prognosis

Outcomes
Examinati Interventio
on n
 Patient Examination
• Patient history
• Psychsocial factors
• Tests and measures
 Patient History
• Focal or generalized tone
• Evolution of spasticity
• History of intervention
• Past medical history
• Comorbidities
• Chief complaint
• Patient’s/caregiver level of
understanding
 Psychosocial Factors
• Coping strategies/parenting styles
• Learning styles
• Cognition
• Family/community support
• Funding sources
 Tests and Measures
• Muscle Performance
• Range of Motion
• Integumentary Integrity
• Pain
• Orthotic, Protective, and Supportive Devices
• Fatigue/Cardiovascular Endurance
• Posture
• Reflex Integrity
• Neuromotor Development and Sensory
Integration
• Self-care and Home Management
 Tests and Measures
for Muscle Performance
• Static and dynamic muscle tone
• Muscle strength and selective
motor control
• Function
 Static Muscle Tone
• Ashworth and Modified Ashworth
scale
• Tardieu scale
• Spasm Frequency scale
• EMG/ H Reflex
 Modified Ashworth Scale
Scor Criteria
e
0 No increase in tone
1 Slight increase in tone (catch and release at
end of ROM)
1+ Slight increase in tone, manifested by a
catch, followed by minimal resistance
throughout remainder (less than half of the
ROM)
2 Marked increase in tone through most of
ROM, but affected part(s) easily moved
3 Considerable increase in tone; passive
movement difficult
(Bohannon & Smith,
Modified Tardieu Scale:
(Boyd, 1999)
• Consistent velocity stretch of muscle
• Standard positions for specific muscles
• Note point of resistance to maximal
velocity stretch (R1)
• Note amount of muscle contracture or
muscle length (R2)
• Relationship between R2-R1
 Spasm Scale
Spasm Frequency

Score Criteria
0 No spasms
1 No spontaneous spasms
(except vigorous stimulation)
2 Occasional spontaneous spasms
easily induced
3 >1 but <10 spontaneous
spasms/hr
4 >10 spontaneous spasms/hr
Penn, Savoy, New England Journal of Medicine, 1989, 320:1517-1521.
 Dynamic Muscle Tone
• Observation of Movement Patterns
– Equinus gait
– Scissor gait
– Upper extremity flexion/adduction
– Mass movement postures
• Observation Tips
– Try observing with and without orthoses or
ambulation aids
– Video taping can be very helpful
Additional Examination
Considerations
• Assistive devices utilized
• Seating system
• Positioning
• Functional tasks
• Status of oral medications
 Typical Upper
Extremity

• Shoulder: internal rotation

• Elbow: flexion
• Forearm: pronation
• Wrist/ Fingers: flexion
• Thumb: in palm
 Typical Lower
Extremity Postures
• Hip & Knee Extended
• Ankle Plantarflexed
• Foot/ ankle inverted
OR
• Hip & Knee flexed
• Ankle Plantarflexed
 Consider the Positive
Signs
• Is there:
– Moderate to severe spasticity?
– Static or dynamic spasticity?
– Generalized or focal spasticity?
• What are the effects on:
– Function?
– Comfort?
– Care?
– Safety?
• Is intervention directed at these signs
warranted?
Possible Advantages of
Spasticity
• Maintains muscle bulk and tone
• Helps support circulatory function
• May assist in transfers and
ambulation
• May assist in activities of daily
living
 Consider the Negative
Signs
• Is there a lack of:
– Strength?
– Motor control?
– Coordination?
– Balance and posture?
– Endurance?
• What are the effects on:
– Function?
– Comfort?
– Care?
– Safety?
• Is intervention directed at these signs
warranted?
 Consequences of
Spasticity
• May interfere with:
 ADLs: dressing and hygiene
 Mobility: rolling, sit ⇔ supine, transfers,

ambulation
 Exercise

 Joint range of motion

 Coordination of movement

 Ability to move: ↑ effort

 Tolerance of orthotics/ splints

 Skin integrity

 Ability to sleep/ rest

 Feeding and speech

 Patient Care

 Driving
Clinical Evaluation and
Patient’s Perspective

Most importantly,
Does spasticity interfere with
function, care, or comfort?
Is Spasticity a Problem?
Goals of Spasticity Management

• Decrease spasticity
• Improve functional ability and independence
• Decrease pain associated with spasticity
• Prevent/ limit contractures
• Improve mobility/ ambulation
• Facilitate ADLs/ hygiene
• Save caregiver time & effort
 Gait Assessment
• Foot clearance with swing
• Foot position at late swing
• Step length
• Leg position in stance
• Amount of effort required to
ambulate
 Abnormal Gait in
Spastic Diplegia
• Gait is delayed and requires great effort
• Adducted with IR of Hip
• Increased knee flexion
• Forefoot strike
• Early heel rise
• Excessive lumbar lordosis
• Circumducts or excessively flexes hip-
knee to advance leg
Abnormal Gait with Spastic
Hemiplegia

• Toe strike
• Knee hyperextension
• Posturing of ipsilateral upper
extremity
• Trunk lean
Abnormal Gait with Spastic
Hemiplegia

• To advance LE:
– Hip hiking
– Trunk lean to opposite side
– Circumduction
– Excessive Hip & Knee Flexion
– Vaulting
Abnormal Gait with Spastic
Hemiplegia
 Functional Prognosis:
Primarily Ambulatory
• Balance and safety
• Endurance and energy conservation
• Gait pattern
• Additional areas where skill level
could improve
– Driving
– Athletic performance
 Functional Prognosis:
Primarily Wheelchair
Use
• Transfers, mobility, and safety
• Position and function in wheelchair
• Additional goals could include:
– Fine motor control: switch access
– Speech
– Feeding: oral motor skills
– Preparation for other interventions
 Rehabilitation Therapy
• Stretching • EMG biofeedback
• Casting • Electrical stimulation
• Vibration of the
• Orthoses antagonist
• Weight bearing • Constraint-induced
• Positioning & Movement Therapy
Seating: • Selective Strengthening
-Podus Boots of Antagonist
• Aquatic Therapy
-Versaform
• Handling/ Inhibitory
-Splints/ Bivalves Pressure
-Aircast
• Practice functional
tasks
• Sensory Integration
 Focus on….
• Elongation of shortened tissues
• Strengthening
• Improving motor control
• Address underlying weakness
Treatment Approaches
• NDT:
– Normalize muscle tone/ posture
– Inhibit reflexes
– Facilitate normal movement
 Use of handling/ facilitation

techniques

• Motor Learning
– Practice functional tasks
 Treatment Approaches
• Therapeutic Exercise:
– Stretching and ROM
– Active assistive, active, & resistive exercise
– E-stim. (fatigue OR strengthen)
– Weight bearing
– Aquatic therapy
– Rhythmic rotation
– Contract-Relax
– Handling/ key points of control Inhibitory pressure
– Ice
– Warmth
– Biofeedback
Treatment Approaches
• Functional Training:
– gait, ADLs, mobility, school-based (to
enhance education)
– Consider equipment and
environmental adaptations to
maximize function
 Other Treatment
Approaches
• Restraint-induced
• Play
• FES
• School based vs. medically based

• ***Not just one approach…blending of

what’s effective for
patient
 Positioning

• Positioning: (in bed, w/c, and other)

– Podus boots
– Versaform
– Splints
– Aircast
Positioning
 Casting/ Splinting
• Inhibitory Casting
• Serial Casting
• Bivalve Splints
• AFOs
• SMOs
• Upper Extremity/ Hand Splints
 Inhibitory Casting

• Theoretical Principles:
– Static positioning interrupts stretch
reflex
– Circumferential casting provides
neutral warmth and constant pressure
– Decreases variability of cutaneous
sensory input which can elicit stretch
reflex
– Promotes changes in muscle tendon
length and sarcomere distribution
 Inhibitory Casting
• Indications:
– Elevated muscle tone present
– Full/ functional ROM present
– Little isolated, active (non-synergistic)
movement is present
– “Holding” or “posturing” is observed
 Inhibitory Casting
• General Principles:
– Cast in sub-maximal range
– Leave on 3-5 days
– Complete a thorough assessment
after removal
– Apply new cast or bivalve ASAP
– Use with abnormal movement
 Serial Casting
• Theoretical Principles:
– Low-force, long-duration stretch
produces residual elongation of
connective tissue
– Gentle, prolonged stretch results in
cell division
– Provides inhibitory effect
 Serial Casting
• Indications:
– Spasticity is present
– Loss of PROM is significant
 Serial Casting
• General Principles:
– Apply cast in submaximal range
– Leave on 5-10 days
– Complete thorough assessment after removal
– Casting multiple joints
– Decide what to do next (cast or splint):
 If cast again , do immediately

 If splinting, do ASAP
Therapist Evaluation Prior
to Casting
• Cognitive status
• Sensation
• Skin integrity
• Effects of positioning and gravity
• Psychosocial issues
• Recommendation for other interventions
(botox)
• Type of casting: serial vs. inhibitory
• Quality of motion:
– Active vs. passive
– Isolated vs. synergistic
– Do ALL prior to casting and
again AFTER each cast
 Contraindications for
Casting
• Medically unstable
• Edematous areas
• Fragile skin
• Compromised circulation
• Agitation and confusion
• Impaired Sensation
• Open Wounds:
– Abrasions
– Lacerations
Contraindications for
Casting
• Multiple Extremities
• Multiple Joints
• Bony Malformations:
– Subluxation
– Unhealed fracture
– HO
– Loose bodies
– Arthritis
Cast Padding
 Caregiver Monitors:

• Pulse and respirations

• Skin temp
• Skin color
• Pain
• Edema
• Reddened areas or blisters
• Cast condition
• Limb position
General Info on Casting
• Casting is usually most effective proximal  distal;
will see some distal inhibition with proximal
inhibition

• Need to prioritize individually per patient needs,

medical status, and tolerance

• Heat generated in a cast may be in itself inhibitory

for tone
 More General Info on
Casting & Spasticity
Management
• Air splints are generally ineffective as means of inhibiting
tone due to softness and inconsistent pressure; best used for
positioning during treatment

• Whole body positioning may be beneficial; primitive reflex

patterns and synergies need to be inhibited to decrease tone

• Serial casting uses same principles of Inhibitory, but low

load, prolonged stretch = physiologic changes (↑ in
sarcomeres) = permanent change in muscle length
Long Arm Cast
 Drop-out Elbow Cast

Gillen G & Burkhardt, A, Stroke Rehabilitation: A Function-Based Approach. Mosby: St. Louis, 1998
Drop-out Cast
Hand & Wrist Casts
 Hand & Wrist Casts

Gillen G & Burkhardt A, Stroke Rehabilitation: A Function-Based Approach. Mosby: St. Louis, 1998
Leg Casts
 Casting

Another tool in our bag

-cost-effective vs medical
-fairly non-invasive
-it works!
 Therapists
• Input for selection of muscle injection/ surgical
intervention/ medication based on functional
picture
• Feedback to physician regarding effects of
medical management
• Suggestions/ ideas for future management to
maximize function
• Seek input of other team members
• Monitor patient for changes in status
• Provide inhibition & facilitation techniques;
especially after casting &/or medical
treatments
• Serve as referral source in community
• Assist with oral motor skills
 Reassess Equipment
Needs
• Seating system
• Standing equipment
• Orthotics
• Bathroom equipment
• Assisted technology
• Augmentative communication
 Adult Outcomes:
General
• Functional Independence Measure (FIM)
• Functional Assessment Measure (FAM)
• Canadian Occupational Performance
Measure (COPM)
• Goal Attainment Scaling (GAS)
• Timed Up and Go (TUG)
• Pain Scales
 Adult Outcomes:
General
• Barthel Index
• Observational Gait Scale (OGS)
• Sickness Impact Profile (SIP)
• SF-36 (QOL measure)
• 3-Dimensional Gait Analysis
(3DGA)
Adult Outcomes: Stroke
• Chedoke-McMaster Stroke
Assessment (CMSA)
• Berg Balance Scale (BBS)
• Tinetti Balance Scale
 Adult Outcomes: MS
• Multiple Sclerosis Functional
Composite (MSFC)
• Minimal Record of Disability for MS
(MRDMS)
• Modified Fatigue Impact Scale
(MFIS)
 Evidence: Botox
• Effective and safe to manage
spasticity in children:
– Love et al
– Desloovere et al
– Boyd and Hays
– Chambers
– Fragala
– Graham
– Houltram et al
 Evidence: Botox
• and Adults:
– Hesse et al
– Pierson et al
– Yablon et al
– Simpson et al
– Graham and Rawicki
 Evidence: Casting
• Effective in improving ROM and reducing
spasticity
– Hill
– Barnard et al
– Nash
– Mortenson and Eng
– Cottalorda et al
– Lehmkuhl et al
– Booth et al
 Evidence: Botox vs.
Casting
• Houltram et al
• Flett et al
• Corry et al
– Significant improvement in tone
reduction and gait for both groups
– Botox was preferred treatment by
caregivers
– Botox lasted longer
 Evidence: Botox &
Casting
• Booth et al: both together caused faster
results (improved gait and ROM) as
compared to just casting
• Desloovere et al: Group casted AFTER
Botox improved more with 3DGA than
group casted PRIOR to Botox
• Graham et al: Less regression and loss
of function if casted with Botox than if
surgery
Cases
 Jeffrey

• 6 y/o; CVA at birth/ CP: Left Hemi

• OT/PT since 1y/o, 1-2X/ week
• Spasticity Left upper & lower extremities
• Impaired Left sensation/ position sense
• Gait: toe walker, decreased step length on right,
circumduction to advance left leg
• Impaired balance: especially in standing
• Short hamstrings: poor sitting posture
 Jeffrey
• Treatment:
– Botox: left finger and wrist flexors; left plantarflexors
& hamstrings
– Inhibitory Casting left foot/ ankle in DF
– Inhibitory Casting left hand/ wrist in neutral
– Weight bearing:
 Hands and knees
 Side-sitting
 stance
– Dynamic stretch to hamstrings and gastrocs
– Splints worn at nighttime
– Home Program: long sitting while playing games, use
of left hand, stretching, wrist
extension and ankle DF
– Coordination & balance activities
 Jeffrey’s Outcome

• Began walking with occasional heel strike/

flat foot
• Improvements with balance during gait & on
stairs
• Began jumping (still uses R > L)
• Able to move ½ kneel ⇒ stand over left leg
• Hops on left leg with help
∀ ⇓ Limp (still present)
∀ ⇑ speed/ started running
 Jeffrey’s Outcome
• Ongoing:
– lack of heel strike
– decreased push-off on left
⇓ stability in Quad
– uses R > L
– Mild “limp”
– Difficulty with advanced motor/
coordination activities
 Jeffrey’s Outcome
• Opens hand & fingers
• Controlled grasp & release
• Can obtain neutral forearm position
∀ ⇑ strength proximally
• Function: uses left as assist
 Ex: shoe tying
• Began walking with occasional heel strike/ flat foot
• Improvements with balance during gait & on stairs
• Began jumping (still uses R > L)
• Able to move ½ kneel ⇒ stand over left leg
• Hops on left leg with help
∀ ⇓ Limp (still present)
∀ ⇑ speed/ started running
 Jeffrey’s Outcome
• Ongoing:
– Grip strength= poor
– Lacks full supination
– Trunk substitution for IR and ER
– lack of heel strike
– decreased push-off on left
⇓ stability in Quad
– uses R > L
– Mild “limp”
– Difficulty with advanced motor/
coordination activities
 Sarah
• 21y/o, TBI due to MVA
• Rancho II
• Significant Spasticity throughout
extremities, trunk, neck
• Video:
 Conclusion
Choose the treatment or treatments
that address the positive and
negative signs interfering with
attainment of the patient and
family/caregiver goals, keeping in
mind the psychosocial and medical
factors.

COMMUNICATION:
With other team members
With Physician
 Credits
• To Edward Wright, MD and LeaAnn Brittain, ME,
OTR who originally developed parts of this
presentation
• To Giulianne Krug, ME, OTR for providing
information on spasticity and benefits of casting.
• To Medtronics for data and information, graphics
and formatting used within this presentation.
 References and
Suggested Reading

10- page list of references can be viewed

separately