Transcript Document
Hereditary Spastic Paraparesis How can Physiotherapy help? Meredith Wynter Senior Physiotherapist CP Health, Royal Children’s Hospital Overview • • • • HSP Spasticity Treatments for children Physio approaches HSP • Many different names – Hereditary spastic paresis/ paraplegia – Familial spastic paraplegia – Strumpell-Lorrain disease: first described 1880. • Characteristically: progressive spasticity of legs (hams, quads, calves) • Spasticity >> weakness • 10-60% sensory involvement • 25-45% asymptomatic • Prevalence 2-6/100,000. Rare Classification systems • Genetic markers • Age of onset: – Type 1 : Early – slower progression – Type 2: > 35y, more rapidly progressive disease, muscle weakness, sensory loss, urinary involvement more marked – Onset varies infancy - > 80yo. Clinical presentation – pure HSP • Delay in walking • Leg stiffness, urinary disturbance (urgency, hypertonic bladder), premature wear of shoes • Cardinal signs: – spasticity, hyperreflexia, extensor plantars, weakness in pyramidal distribution (legs) – Family history – Circumducting gait – Weakness: iliopsoas, tib ant, hams. • Can have discrepancy between severe spasticity and mild / absent muscle weakness. – “wheelchair bound patient from spasticity, but normal strength” SPASTICITY • Major clinical feature • Generally a major cause of discomfort or functional limitations • Many resources for treatment of spasticity • Long term secondary effects of spasticity can become prime disability – Leads to contractures ( paediatric) – Pathologic condition of soft tissue – Stiffness, fixed shortening, loss of range Spasticity in cerebral palsy has both neurophysiological and musculoskeletal components……our modern endeavours in treatment are designed to `equalise the race’ between bone and muscle growth Flett 2003 SPASTICITY • • • • • • • • Physiotherapy Oral medications Orthotics Orthopaedic surgical interventions (Multilevel surgery) Electrical stimulation Botulinum Toxin Injections Selective Dorsal Rhizotomy ( SDR) Intrathecal Baclofen Infusion ( ITB) Physiotherapy • • • • • • • Motor Control Task training Stretching Strengthening Electrical stimulation Serial Casting Splinting Treatment with Botulinum Toxin • • • • • • Many treatments world wide Gold standard Safe Reversible Helps with growth related contracture Improves function Botulinum Toxin Type A • What is it? – A purified form of the neurotoxin responsible for botulism found to be effective in reducing spasticity - CP, ABI, SCI • How does it work? – Temporarily blocks neuromuscular conduction by inhibiting the release of acetylcholine – Partial paralysis of targeted spastic muscle(s) Assessment • • • • • • Activities Strength, range of movement, gait video Participation Goals, patient and medical Maintenance of skeleton and muscles Caution for excessive weakness How is it used? Intramuscular injection for Focal spasticity Calf injection sites Why treat spasticity with BTX-A? • • • • • • • • improves walking reduces pain and discomfort Ease of care and hygiene Enhance the effects of therapy Avoid early or repeated surgery / delay surgery Assist in prevention of contracture improved tolerance to serial casts improved tolerance to orthoses and splinting Active physiotherapy program • muscle length and flexibility • serial casting commencing ~ 2 to 3 weeks post injection if required (earlier in acute ABI) • strengthening • targeted motor training • functional skills • splinting and orthotic intervention • home and school program • aim to achieve carry over beyond pharmacological effects of BTX Exercise • Something enjoyable – strengthen and stretch • • • • • • • Gym training Swimming Cycling Yoga / Pilates Martial arts, karate etc Horse riding Rock climbing Thank you [email protected] 15 minutes stretching every day Enjoyable physical activity