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Spasticity: Baclofen and BoTox

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Tyler Wamsley

on 24 February 2013

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Transcript of Spasticity: Baclofen and BoTox

Oral Baclofen Why use oral baclofen? Intrathecal Baclofen Botulinum Toxin A (BT-A)
Injections Spasticity Occurs when the brain is unable to send descending signals to help offset or inhibit the excitatory signals Treatment of Spasticity Oral/Intrathecal Baclofen and BoTox Effectiveness and the Physical Therapist Role Complications Role of the Physical Therapist (Criswell, 2006)
-Description, characteristics, and a schematic diagram
-Toe walking
-Crouched gait
-Scissoring Primary LE Complaints in Children with CP (Kazon, 2012) -The effects of dorsiflexion NMES and PT in children with CP after BT-A injections
-Measurements
-Modified Ashworth Scale (spasticity)
-Medicapteurs Fusyo Pressure Platform (static)
-Berg Balance Scale (functional)
-Data collection
-Motor PT combined with DF NMES or motor PT alone, after receiving BT-A injections BT-A and NMES (Ciftci, 2013) -Children with chronic NM disorders
-Negatively affects QOL
-Perioral skin infection and breakdown, soiling of clothing from saliva, etc.
-Safety and efficacy of US guided BT-A submandibular gland injections
-Teacher Drooling Scale (TDS)
-Four and 12 week results BT-A Use in Excessive Drooling (Criswell, 2006) -Neuromuscular block -> muscle paralysis
-Seven botulinum neurotoxin serotypes
-A, B, C1, D, E, F, and G
-BT-A and BT-E
-Two main BT-A preparations available
-Botox and Dysport
-1:3 = identical effects BT-A Mechanism of Action TBI What is ITB Benefits Continued CVA FDA approved ITB in 1996
Utilizes a programmable pump inserted in the abdomen
Catheter
C1-C4 for UE and LE involvement
C5-T2 for UE involvement
T10-T12 for LE involvement
Try to wait a year to see if the spasticity will improve (Uchiyama, 2012) (Ivanhoe, 2006) Reduction in spasticity
improvement in gross motor function
improvement in ambulation
Increased quality of life (QOL) (Zdolsek, 2006) Baclofen has been successful in decreasing tone post-CVA
Decreasing spasticity post-CVA improves effectiveness of rehabilitation (Ivanhoe, 2006) Dysautonomia: 5 or more of following present
profuse sweating, tachycardia, hypertension, muscle hypertonia, hyperthermia, tachypnea
Improvement in these patients were most significant with ITB was used
Allowed for increase function and mobility
College and Hobby (Drums) (Hoarau, 2012) Children > Adults
Side effects include:
Listlessness
Seizures
Drooling
Hypotonia
Constipation
Urinary Retention
Surgical pouch infection
Benefits outweigh the side effects! (Zdolsek, 2011) Benefits ITB allows the medication to bypass the BBB
Allows for lower overall dosage of medication to reach therapeutic window
The first pass affect within the liver is avoided
Improvements:
body care/movement
mobility
communication
sleep/rest
social interest (Ivanhoe, 2006) (Ordia, 2002) What are the side effects? Sedation
Reduction of epileptic threshold
Respiratory depression
Confusion
Dizziness
Headache
Insomnia
Depression
Tremor
Ataxia
Paresthesia How does it work? Start with a low dose and gradually increase the dosage to within the therapeutic window (maximum dose 120mg/day)
When discontinuing use, it is important to gradually wean off the drug as well
GABA agonist which crosses the blood-brain barrier and binds the GABA receptors of the spinal cord
Hyperpolarization occurs at the presynaptic membrane and leads to a restriction of calcium influx
Endogenous transmitter release is reduced Spasticity in Specific Populations Stroke
Spinal cord injury**
Multiple sclerosis
Traumatic brain injury
Cerebral palsy
Idiopathic spastic paresis
Neuro-degenerative diseases

Spasticity is the only symptom of upper motor neuron syndrome that is accessible to drug therapy, but it requires a high dosage to enter the blood-brain barrier

**According to Taricco et al, further research is needed to justify treatment in SCI patients Spasticity should always be treated with physical therapy, but pharmaceuticals can help
Spasticity can have a profoundly negative effect on function
Easy to administer in tablet form
Treats systemically
One of the least expensive options along with physical therapy
Most widely used of the oral anti-spasticity agents (Simon 2010) (Scheinberg, 2006) (Rekland, 2012) (Simon, 2010) Hallucinations
Orthostatic hypotension
Dry mouth
Visual accomodation issues
Nausea
Vomiting
Constipation
Diarrhea
Hyperhidrosis
Rashes
Aggravation of a preexistent dysuria (Simon, 2010) (Simon, 2010) (Scheinberg, 2006)
(Taricco, 2006) (Rekland, 2012) (Hassan, 1980) Guiding Treatment Approach Three questions a physician should ask himself to guide the choice of treatment:

Is the spasticity problematic?

Is it the main cause of disability?

Is is localized or widespread? (Simon, 2010) Be a part of a multi-disciplinary team
Keep the individual patient and his/her goals in mind
Rehabilitation/management of spasticity
Patient and family education
Adaptive equipment and assistive devices (i.e. brace, wheelchair, etc.)
Minimize side effects/symptoms of withdrawal by ensuring gradual progression of dosage of oral baclofen
Identify side effects that may affect rehab (i.e. fatigue, drowsiness, etc.) and address them appropriately (Simon, 2010) BT-A Use in Non-ambulant children with CP BT-A effects on the ease of care and comfort
Repeated injections vs. single injections
Groups receiving PT/injection
Gross Motor Function Classification System (GMFCS)
GMFCS V = non ambulant
Most of the available research ...
Data collection
(Thorley, 2012)
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