1 / 48

Pharmacological and Surgical Procedures for the Treatment of Spasticity

Pharmacological and Surgical Procedures for the Treatment of Spasticity. Luigi Piccinini M.D., PM&R Scientific Institute «Medea» Bosisio Parini (LC) Italy. Spasticity Reduction vs Function. Spasticity = pathological factor Spasticity = tool for function

melia
Download Presentation

Pharmacological and Surgical Procedures for the Treatment of Spasticity

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pharmacological and SurgicalProcedures for the Treatment of Spasticity Luigi Piccinini M.D., PM&R ScientificInstitute «Medea» Bosisio Parini (LC) Italy

  2. SpasticityReduction vs Function • Spasticity = pathologicalfactor • Spasticity = tool for function • Spasticity + MuscleWeakness

  3. «May the force be with you» (Starwars) • Considermusclestrength and weakness (Piccinini)

  4. Aims of Treatment • Painreduction • Functionalimprovements • Facilitate use of orthosis • Preventsecondaryproblems (muscle & bone deformities) (Early Treatment) • Facilitate nursing and caring

  5. Treatment Options General SDR Oraldrugs ITB Reversible Not reversibile BTX Surgery Focal

  6. OralDrugs

  7. OralDrugs • Diffusedspasticity • Mild/moderate Spasticity • Too young for otheroptions

  8. Side Effects • Sedation • Sleepiness • Increasedsialorrhea • Excessivehypotonia • Hypotension

  9. Baclofen (Lioresal) • 5 mgs/day • Increasedosage of 5 mgseach 3-4 days • Maxdosage: ???

  10. Questions?

  11. BotulinumToxin

  12. BotulinumToxin

  13. BotulinumToxin • Identifyfunctionalproblem • Measureit • Intervention • Outcomemeasurement • Maintainimprovement

  14. BotulinumToxin • Safe • No anaphylacticreactionsreported • Avoid use duringpregnancy

  15. BotulinumToxin • Botox • Dysport • Xeomin • ………

  16. BotulinumToxinDilution • 1 cc • 2 cc • 5 cc • ………………. • Reduced or increaseddiffusion

  17. Primary Non- Responders • Musclefixedcontractures • Subclinicpreviousbotulism • USA Armyimmunization

  18. Secondary Non-Responders • Antibodies in 5-10% pts

  19. AdverseEvents BoNtA Placebo • > Falls 9,3% 3% • Pain 2,3% / • Local weakness 2,3% / • General weakness 1% /

  20. Therapeuticaleffect • Begins in 3-4 days • Maxeffect: 2-3 weeks • Duration: 3-6 months

  21. Action 2 3 1 4 5 Adapted from: dePaiva et al. PNAS 1999, 96:3200

  22. Repeat treatment • Samemuscles: 3 months • Differentmuscles: 1 month

  23. Until……… • Musclefixedcontracture • Antibodies

  24. InjectionTechniques • Free? • EMG guided? • CT guided? • US guided ?

  25. Sedation • Midazolam? • EMLA? • Spray Ice? • ???

  26. CombinedTherapies • BoNtA + PT • BoNtA + orthosis • BoNtA + casting /serial casting

  27. Casting / Serial Casting • 1 week afterinjection • Removeafter 2 weeks • Possible re-casting with increaseddorsiflexion • Afterremoving, orthosis + PT

  28. Results • OxygenConsumption • HR • Endurance • Improvement of kinetic and kinematicparameters

  29. Questions?

  30. IntrathecalBaclofen

  31. IntrathecalBaclofen

  32. ITB Advantages • Reduced side effects • Reducedeffective dose compared to oraldrug • Telemetricprogramming

  33. ITB: Effects • Improvement of ADLs • Improvedcompliance for PT • Reduce pain • Sleepimproving

  34. ITB Management • Bolus test • Goodresponsepumpimplantation • Progressive dose increaseuntiloptimaleffect • Effectmonitoring • Refill

  35. ITB PumpImplantation

  36. ITB Pump Programming

  37. ITB Advantages • High concentration in CSF • Reduced side effects • Reducedspasticityonlyduring the day • Increasedwalkingability • Increasedcomplianceduring PT • Reducedpain • Reversibility

  38. ITB Disadvantages • Surgery • Management difficulty • Periodicsurgery • Complications

  39. RelationshipOrthopaedicIssues/SpasticityTreatment • Givepriority to primaryproblems • Correctlaterorthopaedicdeformities • Youcouldavoidorthopaedicsurgery

  40. Post- Surgery • Rehabilitation Center • Progressive increase of drug flow (20%/day) • Complicationsmonitoring • Posturalassessment • Evaluation for assistivedevices and/or orthosis • Encourage the achievement of new motor pattern

  41. Complications • Infectionsremove • CatheterkinkingXRaysurgery • CathetercollapseXRaysurgery • Leaking

  42. Removal Management • Gradual flow reduction (20%/day) • Oraldrugs • Pumpswitch-off / pumpremoval

  43. Questions?

  44. Whatabout the otheroptions?

  45. Rhyzotomy • No experience in HSP (only CP) • Notreversible

  46. OrthopaedicSurgery • Notspecific for spasticity • Secondaryproblems

  47. Aims of Treatment • Rule # 1: choose THAT treatment for THAT spasticity in THATpatient

  48. Gracias! luigi.piccinini@bp.lnf.it

More Related