Evolution of self-care and functional mobility after single-event multilevel surgery in children and adolescents with spastic diplegic cerebral palsy.

AIM: To explore the evolution of self-care and functional mobility after multilevel surgery in children and adolescents with spastic diplegic cerebral palsy and to identify factors affecting these outcomes. METHOD: Thirty-four participants (22 males, 12 females) were evaluated before surgery, and at 2 months, 6 months, 1 year, 18 months, and 2 years after surgery. Self-care was assessed with the Pediatric Evaluation of Disability Inventory Dutch edition. The Mobility Questionnaire47 (MobQues47) and Functional Mobility Scale (FMS) were used to measure functional mobility. RESULTS: All outcomes revealed a significant decrease 2 months after single-event multilevel surgery (SEMLS) (p-value between <0.001 and 0.02) followed by a significant increase at 6 months (p<0.001 and p=0.045). Between 6 months and 1 year, a significant increase was also revealed for Mobques47 (p<0.001), FMS (p≤0.008), and the Pediatric Evaluation of Disability Inventory Functional Skills Scale (PEDI-FSS) (p=0.001). Improvement continued until 18 months for the PEDI-FSS. Initial score, initial muscle strength, Gross Motor Function Classification System level, age, and number of surgical interventions significantly influenced time trends for self-care and/or functional mobility. INTERPRETATION: Most preoperative scores are regained at 6 months after SEMLS. Further improvement is seen until 18 months. Participants with a higher functional level before surgery will temporarily lose more than participants with lower initial functional ability, but they also fast regain their function. WHAT THIS PAPER ADDS: Self-care and functional mobility decrease significantly in the first months after single-event multilevel surgery (SEMLS). Six months after SEMLS most preoperative scores are regained. Impact of SEMLS is more pronounced for functional mobility than for self-care. Muscle strength and functionality at baseline are important influencing factors on the evolution after SEMLS.

Hidden Medical Devices in the School Setting: What the School Nurse Needs to Know About the Safe Use of Baclofen Pumps.

One of the "hidden" medical devices in the school setting is the baclofen pump, which is used for the treatment of spasticity. The goals of spasticity treatment are to decrease muscle tone, deformity, and pain in order to maximize function and ease of care for both child and caregiver. The use of an intrathecal baclofen pump, often for children with cerebral palsy, spinal cord injury, brain injury, or stroke, has been effective in spasticity treatment. It is important for school nurses to be aware of the safety implications associated with this type of device. The Specialized Health Needs Interagency Collaboration (SHNIC) program at the Kennedy Krieger Institute has complied education and materials that explain the use of baclofen pumps in children with spasticity and the role of the school nurse in providing staff training, developing emergency care plans, and creating a safe school environment for children with special health needs.

[Management of symptoms associated with spasticity in patients with multiple sclerosis]. / Manejo de los síntomas asociados a la espasticidad en pacientes con esclerosis múltiple.

OBJECTIVE: To describe the role of nurses in the management of symptoms related to spasticity in patients with multiple sclerosis (MS). METHOD: A descriptive study was developed based on a questionnaire on spasticity in MS patients. The questionnarie was completed through an anonymous tele-voting system at a national meeting with nurses involved in the management of these patients. RESULTS: Apart from fatigue, according to the opinion of the participants, the spasticity symptom associated with MS most notified by patients was difficulty in walking, followed by spasms and pain. Participants thought that it is important that nursing takes: 1) a role in identifying these symptoms, 2) should focus on the detection of the triggering or aggravating factors, and 3) on providing support in the assessment of the level of spasticity. It is important to inform about the correct use of anti-spasticity drugs, how to adjust the dosage and side effects of treatments, including cannabinoids via an oromucosal spray, titrating its doses according to each patient, and monitoring its tolerability, efficacy and adherence. Although there are usually resources to follow up these patients, there are still important gaps, including the lack of a specific follow-up protocol. CONCLUSIONS: Although all the participants are experts in the management of patients with MS, there is still diversity in the functions they perform, and the available resources they have in their hospitals. Nurses act as a key element in the process of identification of symptoms, training and monitoring of these patients with spasticity in EM.

Improving hand hygiene after neurological injury.

Caring for hands tightened by spasticity after stroke, brain injury or other neurological conditions can be challenging for care staff. Opening and cleaning the hand, managing pressure areas, cutting nails and reducing pain becomes more complex if muscles are tight and short. Hand hygiene is key for staff but literature on patients' hand and nail care is lacking, so specialist education and care planning may be needed to help staff ensure these activities are done well. This article outlines the importance of maintaining patients' hand hygiene, explores the barriers to providing effective care and discusses how they might be overcome.

Clinical measurement of limb spasticity in adults: state of the science.

Spasticity is a neuromuscular dysfunction characterized by tight or stiff muscles. Spasticity occurs across the spectrum of upper motor neuron disease and complicates the course and quality of life of those affected. Accurate and precise assessment of spasticity is the first step in providing safe and effective treatments to patients for management of spasticity. Examiner evaluations (Ashworth Scale, Modified Ashworth, and Visual Analog Scale) and patient self-reports (Visual Analog Scale and Numeric Rating Scale) are used to assess spasticity in clinical practice. We reviewed the biology of spasticity and summarized research that assessed properties of scores obtained from clinical scales when used in a variety of upper motor neuron diseases. The definition of spasticity was inconsistent. Rater reliability or agreement on clinical scales varied widely. Correspondence with electromyogram results was mixed. There was dissimilarity in patient reports and examiner assessments. Scores from clinical scales are responsive (decrease after initiation of treatment with known effectiveness), but the utility of scores for indexing individual change associated with the natural history of upper motor neuron disease is unknown. Future research incorporating patient reports and examiner findings over time will help to clarify the definition and capture the essence of spasticity.

The nurse's role in assessing and measuring spasticity.

Spasticity is a common feature of neurological conditions such as multiple sclerosis, cerebral palsy, stroke, brain and spinal injuries. The management of spasticity remains a challenge for not only the person with spasticity but also their family, carers and healthcare professionals. Accurate assessment and measurement is essential to ensure individuals receive the most appropriate interventions.

Care provider assessment of intrathecal baclofen in children.

Intrathecal baclofen is used increasingly to manage severe spasticity in children. Before implanting the baclofen pump, care providers typically ask how it will benefit their child. The purpose of this study was to describe the perceptions of care providers about intrathecal baclofen for management of spasticity in 80 individuals (52 males, 28 females). The individuals were younger than 22 years at the time of implantation (mean age 11 years, SD 5 years; range 3 to 21 years). Participants had been implanted with the pump for a minimum of one year at the time of evaluation. The most common diagnoses were quadriplegic and diplegic cerebral palsy and traumatic brain injury. Most participants were at level IV and V on the Gross Motor Function Classification System. After pump implantation most participants had tone reduction on the Ashworth scale of 1 to 1.9 in the lower extremities and 0 to 0.9 in the upper extremities. Lower extremity range of motion was maintained in 43 of 51 individuals (84%) and lost in 8 participants (16%). Complications requiring surgery occurred in 63 of a larger group of 152 patients (incidence per patient-year of follow-up was 0.19). Thirty-one of the 80 children had orthopedic procedures after pump placement. Only one of these was unexpected and none had rapid progression of scoliosis. Most treatment goals were achieved. Goals most commonly chosen (decreased pain, prevention of worsening of deformity, and improved ease of care) were improved in 91%, 91%, and 88% of participants respectively. Ninety-five per cent of care providers agreed that they would have this procedure performed again (81% strongly agreed, 14% slightly agreed). All care providers reported improvement in scores on the Caregiver Questionnaire. This information has been helpful to families considering intrathecal baclofen therapy.

A self-report of quality of life of patients receiving intrathecal baclofen therapy.

The purpose of this study was to explore through a department quality improvement tool a possible relation between quality of life (QOL), complication rates, and length of intrathecal baclofen (IB) treatment as reported by patients receiving IB therapy in a community-based rehabilitation center outpatient clinic. A second objective was to examine complication rates among the clinic's patients. No conclusions could be drawn as to the relation between QOL, various reported complications, and length of treatment. A rank order frequency of areas reported by respondents to have the greatest impact on their QOL could be extrapolated from the data collected. In addition, complication rates among the patients who responded to the survey could be reported. Surveys from 49 patients about their experiences with IB therapy were analyzed. Respondents included 30 adult and 19 pediatric patients. Thirty-six patients (73%) had used the IB pump for 1 year or more. The survey included questions about QOL, complications, and length of IB treatment. Forty-three respondents (88%) stated they felt that their QOL had improved with IB therapy. Four patients (8%) responded that they were not sure that it had, and only 2 patients (4%) said that IB had not improved their QOL. The most frequently reported positive effects on QOL were reported in the following areas: spasticity control without the sedative effect of oral medication; ease of care for caregivers; easier positioning; less pain/increased comfort; and improved patient transfers. High ratings of improvement in the patients' QOL were reported despite a reported overall complication rate of 39%. The most common complications cited were infection and catheter breakage or disconnect. The overall infection rate for respondents was 10% (5 patients of the 49 surveyed reported infection). The rate of catheter breakage or disconnect was also 10%. Despite the complications reported, 46 patients stated they would recommend baclofen treatment to others. Three patients did not respond to the question. None of the patients said they would not recommend baclofen to others.

[Botulinum toxin--interventional neuropediatrics in spastic movement disorders in childhood]. / Botulinumtoxin--Interventionelle Neuropädiatrie bei spastischien Bewegungsstörungen im Kindesalter.

Botulinumtoxin A (BTX) is widely used for the treatment of spastic movement disorders in childhood. Safety and local efficacy of BTX are well documented by the experience of many users and verified by several clinical trials. Indications for the use of BTX in children include facilitation of care, better tolerance of ortheses as well as the quantitative and qualitative improvement of motor abilities. This article differentiates clinical indications for which the use of BTX has been proven from those in which effectiveness is only suspected or is yet unclear.

Spasticity in kids. An intrathecal option.

The painful muscle rigidity and severe spasms suffered by patients with brain and spinal injury can be managed even more successfully than in the past with intrathecal baclofen. For many, it's provided effective relief and improved levels of function.

Treatment of cerebral origin spasticity with continuous intrathecal baclofen delivered via an implantable pump: long-term follow-up review of 18 patients.

OBJECT: The goal of this study was to assess the long-term benefits of managing severe spasticity by using continuous infusion of intrathecal baclofen delivered via an implantable pump. METHODS: Eighteen patients with severe spasticity of cerebral origin, who failed to respond adequately to more conservative treatments, have-been treated with continuous infusion of intrathecal baclofen delivered via an implanted pump. Follow-up review of these patients has lasted between 12 months and 9 years. The patients have been assessed using a variety of tools. Seventeen have had a significant reduction in tone and all have benefited by a reduced need for nursing care or increased function or both. CONCLUSION: Long-term continuous infusion of intrathecal baclofen delivered via an implantable pump offers an effective method for dealing with otherwise intractable spasticity.

Continuous intrathecal baclofen infusions. An introduction and overview.

Continuous intrathecal baclofen infusion (CIBI) is a relatively new treatment modality for severe spasticity of spinal cord origin. Literature review suggests relief of severe spasms and rigidity is proven with CIBI, in patients with spinal cord injury and multiple sclerosis, while ongoing research exists for patients with acquired brain injury and cerebral palsy. Criteria for patient selection, the screening trial process, an outline of the surgical procedure, and generalities of maintenance therapies, will be reviewed broadly as per literature, as well as specifically to the Vancouver experience with adults. Additionally, reported patient outcomes and implications for nursing will be shared.