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Pharmacologic Management Of Spasticity In Cerebral Palsy

J. Mooney, L. Koman, B. Smith
Published 2003 · Medicine

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Cerebral palsy (CP) results from a nonprogressive injury to the developing central nervous system (CNS) and produces motor dysfunction, movement disorders, mentation deficits, and impaired function. Approximately 500,000 to 700,000 children and adults have CP, with an annual incidence of 1.5 to 2.5 cases per thousand live births. Motor dysfunction associated with CP may include spasticity, rigidity, and weakness. Spasticity is “a motor disorder characterized by velocitydependent increase in tonic stretch reflexes that exaggerate tendon jerks, resulting in hyperexcitability of the stretch reflex” (Fig. 1). Excessive spasticity interferes with function, contributes to discomfort and pain, has a negative impact on health-related quality of life, and may produce, over time, deformities of soft tissue, joints, and bone. The most common etiology of the nonprogressive CNS lesion is an insult within the perinatal period. Insults include infection, anoxia, and hemorrhage, each of which occurs more frequently in association with prematurity, very low birthweight, and twin gestations. Although the CNS lesion occurs once and remains constant, expression of this lesion and resultant spasticity and muscle imbalance are affected by the interactions of growth, development, maturation, and disease processes that may confound the clinical picture. Traditionally, nonoperative management of orthopedic issues for patients with CP has included family-based and professional physical therapy, adaptive modalities, orthotics, and casting. The goal of these efforts is to potentiate function. Operative treatment has been used for patients with significant functional impairment, progressive deformity, or pain secondary to fixed contracture or deformity who do not respond to nonoperative treatment. In a severely involved patient, surgery may be indicated to improve positioning and/or hygiene. Recently, there has been an emphasis on management and modulation of spasticity rather than merely addressing the effects of spasticity on the trunk and extremities. Pharmacologic intervention is employed to improve function, maximize health-related quality of life, facilitate other modalities, and/or delay invasive surgical procedures. Some pharmacologic interventions, however, are invasive, and all have inherent morbidity. Pediatric orthopedic surgeons should be cognizant of pharmacologic modulation of spasticity to provide coordinated interventions, since it is often used in conjunction with other nonsurgical methods and may be a valuable adjunct to surgical procedures. There are no spasticity modulation methods that directly effect a fixed contracture, since these require orthopedic surgical intervention. There is evidence that pain associated with fixed deformity may be modulated by pharmacologic agents.
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