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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

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Pharmacological and Surgical Procedures for the Treatment of Spasticity

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  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

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