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A Range of Treatment Options Individualizes Spasticity Management Nonprofit Organization U.S. Postage PAID Twin Cities, MN VOLUME 21, NUMBER 2 2012 200 University Ave. E. Permit No. 5388 St. Paul, MN 55101 651-291-2848 www.gillettechildrens.org CHANGE SERVICE REQUESTED VOLUME 21, NUMBER 2 2012 Angela Sinner, D.O. Pediatric Rehabilitation A Pediatric Perspective focuses on Medicine specialized topics in pediatrics, orthopedics, KEY INSIGHTS neurology, neurosurgery and rehabilitation A Range of Treatment Options medicine. Angela Sinner, D.O., Individualizes Spasticity ■ eTh severity of cerebral palsy symptoms specializes in pediatric To subscribe or unsubscribe from varies widely, but most patients who A Pediatric Perspective, please send an rehabilitation medicine with email to [email protected]. Management have cerebral palsy will have spasticity. a special interest in spina bifida, neurotrauma, and Editor-in-Chief – Steven Koop, M.D. by Angela Sinner, D.O., pediatric rehabilitation medicine specialist ■ l Oramedications to control spasticity spasticity management. She Editor – Ellen Shriner and Debbie Song, M.D., pediatric neurosurgeon will be chosen based on the individual’s Designers – Becky Wright, Kim Goodness tone type, other symptoms and received her doctor of osteopathic medicine degree from Photographers – Anna Bittner, Des Moines University’s College of Osteopathic Medicine Paul DeMarchi tolerance. in Des Moines, Iowa. She completed a physical medicine In the United States, cerebral palsy occurs in approximately two children per 1,000, ■ and rehabilitation residency at the University of Minnesota Copyright 2012. Gillette Children’s Specialty Botulinum toxin A and phenol Healthcare. All rights reserved. 1 Medical School in Minneapolis, and then completed and as many as 1 million people are affected. Cerebral palsy is a motor disorder injections are well-suited for reducing specialty training at Gillette Children’s Specialty Healthcare affecting movement, posture and balance. It may be accompanied by disturbances focal tone issues or if the patient is too through a fellowship in pediatric rehabilitation medicine. of sensation, cognition, communication, perception, behavior and, potentially, seizures. young for more generalized tone reduction treatments. They can also She has made numerous professional presentations on The severity of those symptoms varies widely. However, 70 to 80 percent of patients be used in combination with other topics including pediatric concussion, posterior fossa To make a referral, call 651-325-2200 or who have cerebral palsy have spasticity.2 syndrome, autonomic dysfunction in severe traumatic brain 855-325-2200 (toll-free). spasticity treatments. injury, and spinal cord injury evaluation. Her recent research ■ Intrathecal baclofen therapy is used to has focused on intrathecal baclofen pump management as Spasticity is velocity-dependent resistance that affects muscle movement by provide a generalized reduction in tone. well as hypercalcemia incidence and treatment in spinal increasing deep tendon reflexes and clonus. Spasticity is caused by a disruption in The implanted pump is refilled in clinic cord injury. NEWS & NOTES the baseline inhibitory signals to the stretch reflex, so muscles are stiff and move- every few months, depending on the ments are often jerky and awkward. Consequently, even the simplest activities of daily patient’s medication requirements. Gillette Nationally Ranked in Pediatric Orthopedics living—walking, using hands, talking, swallowing—may be affected. Additionally, the and Pediatric Neurology/Neurosurgery Debbie Song, M.D. constant stress and abnormal growth forces associated with spasticity may cause ■ Selective dorsal rhizotomy is a Pediatric Neurosurgeon Visit www.gillettechildrens.org/ muscle and joint contractures, as well as skeletal deformities. Successfully managing procedure that permanently reduces MedicalStaffBios to learn more about Gillette Children’s Specialty Healthcare is now ranked 12th in the spasticity can increase function and quality of life, while reducing deformity. spasticity by cutting the nerve rootlets Gillette’s specialists. nation for pediatric orthopedics and 39th in the nation for pediatric that transmit the abnormal signals Debbie Song, M.D., is a At Gillette Children’s Specialty Healthcare, we provide a range of spasticity neurology/neurosurgery in U.S. News Media Group’s 2012-2013 associated with spasticity. pediatric neurosurgeon who Clinical Education Best Children’s Hospitals rankings. Last year, Gillette ranked 25th treatments to meet our patients’ varied needs. treats patients who have Find videos and professional presentations. and 44th in the two areas. hydrocephalus, cerebral palsy, Visit our website to view a short video of Spectrum of Spasticity Care spina bifida, and brain and Debbie Song, M.D. performing a selective View the rankings and learn more at www.usnews.com/ spinal cord anomalies. She dorsal rhizotomy surgery. childrenshospitals Our spasticity treatment decisions are based on a variety of factors, include the Inside has a special interest in http://www.gillettechildrens.org/SDRsurgery following: the patient’s age, severity of spasticity and Gross Motor Function ■ Close-up of a selective dorsal Chiari malformations and spinal dysraphism. Song received Classification System (GMFCS) level. We also consider the patient’s goals, along her medical degree from the University of Michigan Medical rhizotomy, P. 2 with the family’s access to follow-up care and ability to comply with the treatment Center in Ann Arbor, Mich. She also completed a neuro- ■ Case study - Multiple therapies surgery residency, surgical internship and neurosurgery recommendations. To meet patients’ individual needs, we provide a range of used to manage spasticity, P. 3 research fellowship there. Additionally, she completed a UPCOMING CONFERENCES treatments, and we may recommend combining treatments to effectively manage clinical research fellowship in the surgical neurology branch spasticity (see the case study on P. 3). (inside flap) of the National Institute of Neurological Disorders and Fourth Biennial Professional and Family Conference for Dravet Spectrum Disorders Stroke at the National Institutes of Health in Bethesda, Md. August 15 – 19, 2012 The spasticity management options Gillette offers include the following: therapy She finished a fellowship in pediatric neurosurgery at the (physical, occupational and/or speech); bracing and splinting; oral or injected University of Texas Southwestern Children’s Medical Center Doubletree by Hilton in Bloomington, Minn. in Dallas. She has extensive publications, including profes- Back Issues of medications like botulinum toxin A; and surgical procedures such as implanting A Pediatric Perspective To register, visit: http://dravet.org/news-events/conference sional journal articles, book chapters and abstracts. She is an intrathecal baclofen pump or performing a selective dorsal rhizotomy. a member of the Congress of Neurological Surgeons and www.gillettechildrens.org/ pediatricperspective American Association of Neurological Surgeons. www.gillettechildrens.org Some patients will require a combination of treatments to The location of the injection is based on a patient’s needs Intrathecal baclofen therapy (ITB) is a drug delivery The procedure may be done for patients who have spastic Multiple Therapies Used to effectively manage their spasticity (see the case study on and goals, and the dosage depends on the patient’s size and system that consists of a pump implanted in the abdomen diplegic cerebral palsy, are 4 to 10 years old, and are typically Manage Spasticity P. 3). To relieve spasticity, we may prescribe some or all of prior exposure to the medication. At Gillette, our patients and a catheter whose tip delivers liquid baclofen (Lioresal) at GMFCS levels I, II or III. Usually, children assessed at A female patient has diffuse tone abnor- the treatments below. typically undergo conscious sedation before botulinum directly to the intrathecal space (where the spinal cord, nerve those levels have impairments affecting their lower malities as a result of schizencephaly. toxin A is injected. Botulinum toxin A has a temporary effect roots and cerebrospinal fluid are contained). Because the extremities, but can walk independently or with the help of Her quadriplegic cerebral palsy is that usually lasts for three or more months. medication is administered intrathecally, a much smaller a walker or crutches. For more information about patient Nonsurgical Treatments associated with significant spasticity and dose is needed to reduce spasticity than is required when the selection for SDR, see Trost J P, Schwartz M H, Krach L E, Oral medications include benzodiazepines like diazepam dystonia of the lower extremities, and is another approach to reducing oral medication is used. ITB therapy is well-suited for Dunn M E, and Novacheck, T F. Comprehensive short-term (Valium) and muscle relaxants such as dantrolene Phenol neurolysis she has mixed tone in her trunk. Consequently, taking care of her spasticity and tone. Phenol is dripped directly on the nerve patients who require a generalized reduction in tone or outcome assessment of selective dorsal rhizotomy. (Dantrium) or baclofen (Lioresal). At times, dopaminergic (bathing and dressing) is difficult. When she was 2 years old, to denature the nerve protein and thus damage the myelin whose goals include a focus on functional changes. Developmental Medicine & Child Neurology 2008, 50: drugs such as levodopa/carbidopa
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