St. Christopher’s Hospital for Children
Spasticity Management Program

Program Overview

Spasticity is a familiar word, but as a medical term it has a precise definition: It is a disturbance of muscle tone characterized by exaggerated, rate-dependent resistance to stretching. For example, a therapist may be able to manipulate a spastic limb slowly and patiently through a full range of motion, but quick and forceful manipulation of the limb encounters strong opposition from muscles that suddenly become tense. Spasticity is not a disease, but it is a common complication of variety of diseases that affect the brain and the spinal cord. In childhood the most common setting for spasticity is cerebral palsy.

Although the neurological diseases that cause spasticity can be responsible for various degrees of fixed disability, spasticity can create an additional layer of interference with activities of daily life. A child with cerebral palsy may have enough strength and balance to walk, but spasticity may make that child’s gait slower, more laborious, and more awkward than it might be otherwise. A more severely affected child may need the assistance of a caregiver for dressing, but spasticity may make dressing more of a struggle than it might be otherwise. For few of the chronic neurological diseases that cause spasticity are there cures, but for spasticity itself there are a number of effective treatments that can make life easier and more satisfying for children and their caregivers.

The first line of care for the child with abnormal muscle tone is an exercise program under the supervision of a physical therapist in the child’s home community. Passive stretching exercises maintain mobility. Active exercises build strength. For selected patients more sophisticated exercise programs are needed to suppress developmentally abnormal patterns of movement and to teach more efficient patterns. The physical therapist also serves as a troubleshooter in the home and school environment, solving problems of access, safety, and comfort. Because the therapist so often has a long-term view of the patient's progress and can serve as an advocate by drawing attention to current needs, the Spasticity Management Program encourages the therapist to participate in the Program's multidisciplinary evaluation whenever possible.

In the young child abnormal muscle tone commonly disturbs the balance between opposing muscle groups and leads to restriction of joint mobility and deformity of growing bones. The orthopedic surgeon works closely with the physical therapist to optimize bone and joint development using exercises, bracing, and surgery. In addition to release of joint contractures and correction of skeletal deformities, the orthopedic surgeon can actually reduce tone by lengthening the tendon associated with the spastic muscle. Thus for decades the orthopedic surgeon has had a central role in caring for children with cerebral palsy. Dr. Peter Pizzutillo provides pediatric orthopedic services through the Spasticity Management Program.

In recent years several advances in clinical neurophysiology, neuropharmacology, and bioengineering have dramatically enlarged the treatment options for children with functional limitations due to spasticity. These advances have introduced 2 new pediatric subspecialists – the child neurologist and the pediatric neurosurgeon – into the mix. Although their services complement rather than displace the traditional role of the orthopedist, active communication and careful planning are necessary to ensure the optimal sequencing and timing of interventions for each child.

The new treatment options are botulinum toxin (Botox) injection, dorsal rhizotomy, and continuous intrathecal baclofen therapy:

• Botulinum toxin (Botox) is a drug that blocks the transmission of electrical signals from nerves to the muscles that they control. A single injection of Botox causes relaxation of an overactive muscle lasting up to 3 months. When the effect wears off, the treatment can be repeated, if it has been helpful. Botox is thus very useful for children whose function is limited by spasticity in a single muscle group or in a small number of muscles. It is also very useful as a temporary measure to control spasticity during a transitional period before a child is mature enough to be considered for some other more invasive, long-term intervention. Child Neurologist Dr. Sabrina Yum makes Botox therapy available through the Spasticity Management Program.
• Muscle tone is controlled through a feedback loop consisting of motor nerves, which carry signals from the spinal cord out to the muscle, and sensory nerves, which carry information about muscle tension and activity back to the spinal cord. Partial surgical interruption of the sensory limb of this feedback loop can achieve permanent reduction of spasticity without loss of strength or sensation. This operation is called dorsal rhizotomy, and it has been used extensively among children with lower limb spasticity related to prematurity to improve the quality of gait. Dr. Joseph Piatt, pediatric neurosurgeon, offers dorsal rhizotomy to carefully evaluated and highly selected patients through the Spasticity Management Program.
• Medications acting on the spinal cord feedback loop can suppress spasticity as well. Oral medications have been available for many years, but their usefulness has been limited by side-effects, such as weakness and drowsiness, that occur at the doses needed to reduce muscle tone. Within the last decade, however, a technology has been approved for use among children that delivers a potent drug, baclofen, directly to the spinal cord by means of an implanted pump. This treatment program is called continuous intrathecal baclofen therapy. The great advantage of this therapy is flexibility: The effect of the drug is routinely previewed before surgery by means of a test dose administered under the supervision of Dr. Joseph Melvin, Child Neurologist. If the patient and family wish to proceed, pump implantation is performed by the Program’s neurosurgeon, Dr. Joseph Piatt. After surgery the daily dose of baclofen can be adjusted over a wide range to achieve desired reductions in muscle tone by electronic reprogramming of the pump. The pump must be refilled every 90 days, but refills can be performed by home nursing services in most communities. If at a later time the patient or the family wish to discontinue treatment, the drug effects are completely reversible. The infusion can be tapered, and the pump can be explanted. Because the pump can deliver baclofen at varying rates and schedules, and because the effect of the drug can be targeted to lower limbs, upper limbs, or both, intrathecal baclofen therapy can be useful for patients with many different patterns and degrees of abnormal muscle tone.

As a child matures, patterns of abnormal muscle tone may evolve, and the consequent functional challenges may change. A comprehensive care plan must not only select among treatment options but also implement treatments in the most helpful sequence at the right time. The monthly, multidisciplinary Spasticity Management Clinic is devoted to strategic treatment planning for children with such complex needs. Coordination of care between hospital-based resources and community services is a priority that requires careful communication with primary physicians and other providers with whom the child may have an existing relationship. This Clinic is administered by Program Coordinator, Kim Fudge.  

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