Dystonia and Spasticity in Cerebral Palsy:
Expanding the Treatment Plan to Optimize Gait Efficiency
Kimberly Wesdock PT, MS, PCS; Susan Blair MSPT; George Masiello BSEET; Chester Sharps MD
Children's Hospital - Richmond, Virginia
Patient History
Gait Data
Spatial & Temporal Parameters:
Left Knee Flexion / Extension
GMFCS III: forearm crutches, R solid AFO, L shoe lift 5 cm functional leg length discrepancy (L<R), scoliosis, Multiple surgeries for recurrent left hip dislocation in Right AFO
w/ Left Lift
addition to medial and lateral hamstring lengthenings, TALs, SPLATT right foot/ankle, derotation osteotomy R hip Markedly reduced knee excursion consistent No history of intrathecal baclofen (ITB) Right AFO
w/o Left Lift
Clinical Data
Dystonia Signs:
Posturing of left hip at rest; inversion posturing of right foot prior to last surgery; hand posturing when not using crutches Non-velocity dependent increase in LE muscle tone in left hip phases, consistent with reduced kinematic adductors and bilateral rectus femoris muscles Absent pyramidal neurologic signs (- Babinski, - clonus, absent Facial grimacing, body builder appearance Treatment Decisions
Oral medication trials of levodopa (Sinemet), trihexyphenidyl Spasticity Signs:
Mild hip and knee flexion contractures (secondary to spasticity) Botox to LEFT adductor longus, adductor magnus, gracilis, and Spasticity in hamstrings – Tardieu Test spasticity angles Impaired distal selective motor control in BLE Obturator nerve block with Marcaine; followed by more permanent Phenol block (physiatrist decision) Consider test trial of ITBPhysical Therapy program Gait Data
Alternating night-time knee immobilizers for KFC Re-eval left shoe lift height with effects on gait velocityStretching program for bilateral hip flexors, rectus femoris, and joint mobilization for posterior knee capsular tightness Strengthening of hip abductors, extensors (including hamstrings), end-ROM quads, and plantarflexors during gait Partial body support treadmill-training program Red = Barefoot, Green = Right AFO with left shoe lift, Blue = Right AFO without left shoe lift
Re-evaluate in Motion Analysis Laboratory to assess Light-Blue = Normal motion
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Source: http://biomotionlabs.com/wp-content/uploads/2011/09/Dystonia-Spasticity-in-CP-Expanding-Treatment-Plan.pdf


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