North East Regional Spasticity Service

1. North East Regional Spasticity Service Dr Jill Kisler Consultant Paediatrician (Neurodisability) Newcastle University Hospitals NHS Trust

2. Introduction • Despite consensus opinion on use of Botulinum Toxin (BTX) in spasticity management for children with Cerebral Palsy evidence for efficacy is limited.1 • Injection of botulinum toxin should be in conjunction with ongoing therapy programme and appropriate orthotic provision.1 • In Newcastle we provide a regional spasticity service (BTX treatment) for children throughout the North of England. • Co-ordination of care between local and regional services is therefore essential. 1Heinen et al. The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy.EurJ Paediatr Neurol. 2010 Jan;14(1):45-66. Epub 2009 Nov 14.

3. Posture and Mobility Management Functional Therapy and Orthoses Acceptable Accessible Integrated to lifestyle Minimal adverse effects Goal Orientated Functional outcome Increase Participation and QOL Orthopaedic Surgery Oral Medication Child and Family Selective Dorsal Rhizotomy Botulinum Toxin Injections Intra-thecalBaclofen

4. The Newcastle Team • Dr Jill Kisler: Consultant in Child Development and Neurodisability • Dr Ki Pang: Consultant Paediatric Neurologist • Mrs Sue Kelly: Superintendent Physiotherapist • Ms Helen Dodd: Senior Physiotherapist • Mrs Janice Pearse: Research occupational therapist • Professor Janet Eyre: Professor of Paediatric Neurology • Dr Rob Forsyth: Consultant Paediatric Neurologist • Mr Will Bliss and Mr Phil Henman Consultant orthopaedic surgeons • Regional Gait Laboratory: Ms Penny Hewart – bioengineer and Mrs Pat Clements - ESP

6. Newcastle Botulinum toxin Service Intra-thecal Baclofen Orthopaedics Regional gait lab University research NECCPS Clinical communication Regional Training Regional Audit Regional Research Sub regional centre or Large DGH Botulinum Toxin Orthopaedics DGH Therapy Orthotics A Managed Clinical Network

7. The Newcastle Clinical Service Lower Limb Service

8. Ambulant Botulinum Toxin Clinic Video gait analysis Clinical assessment Treatment plan: Goals identified Liaison with therapists Serial casting INJECTION Same Day: Midazolam sedation No sedation Deferred: Orthotics Therapy /compliance Casting Bed availability Alternative sedation Entonox / GA Initial Assessment Clinic Gait observation Clinical assessment History / Examination Review of orthotics Other spasticity management (baclofen) Postural Review Clinic Follow up Clinic 6-8 weeks post injection Video gait analysis Clinical assessment Assessment against goals Liaison with Therapists Plan further management Referral to other services Orthopaedics Intra-thecal baclofen Regional Gait laboratory

9. Ambulant Botulinum Toxin Clinic Video gait analysis Clinical assessment Treatment plan: Goals identified Liaison with therapists Serial casting INJECTION Same Day: Midazolam sedation Deferred: Orthotics Therapy /compliance Casting Bed availability Alternative sedation Entonox / GA Initial Assessment Clinic Gait observation Clinical assessment History / Examination Review of orthotics Other spasticity management (baclofen) Postural Review Clinic Follow up Clinic 6-8 weeks post injection Video gait analysis Clinical assessment Assessment against goals Liaison with Therapists Plan further management Referral to other services Orthopaedics Intra-thecal baclofen Regional Gait laboratory

10. Audit of our communication with local therapists following introduction of 6-8 week post injection follow up clinic. • 35 children had 27 physiotherapists • Improvements required in communication • Request for training and update on spasticity management from therapists Evidence based guidance for physiotherapists. APCP 2008

11. Questionnaire ResultsSuggestions for improvement of Service

12. Assessment

13. Video gait analysis • Edinburgh visual gait score [1] • Validated tool • Time effective • Score Sagittal plane only • No force vectors/ EMG [1] Edinburgh visual gait score for use in cerebral palsy. Read et al. J Paed Orthopaedics 2003

14. Postural Assessment • Goniometry • Including assessment of dynamic tone • Selective dorsiflexion • Documentation of GMFCS • Orthotic / walking aid review • Muscle strength • Not always formally

15. Goal Setting • According to: • Long term potential • Child and family’s functional aims • Local therapy programme and goals • Range of Movement • Gait • Compliance with orthotics • Pain • Hygiene and ADL

16. Treatment

17. Technique Ultrasound guidance Sedation Midazolam Entonox General Anaesthetic Personnel Physiotherapy injector Single vs Multi-level Gastrocnemius+/- soleus Posterior tibialis Hamstrings Ilio-psoas Adductors (rectus femoris /peronei) Injection Procedure

18. Post injection • Serial casting • 2 weeks post injection for maximum 2/52 • Communication with local therapists • Stretching • Strengthening • Orthotics • Follow up 6-8 weeks • Assessment of treatment against goals

19. A patient journey! • Ex 30/40 – placental abruption • Bilateral CP – lower limb spasticity • GMFCS 1 • Referred at age 2yrs 2 months • Trial baclofen – not tolerated • Injections • 3yrs 1mth BGS • 3yrs 7 mts BH + BGS • 4yrs 10mths BA, BIP, BGS

20. 4yrs 10mths BA, BIPs, BGS

21. Video • Pre treatment

22. 4yrs 10mths BA, BIPs, BGS • Goals: • ROM: • Increase hip abduction • Reduce Thomas angle • Increase ankle dorsiflexion • Gait: • Reduce hip adduction/scissoring • Flat foot strike (anticipated would be hard)

23. 4yrs 10mths BA, BIPs, BGS

24. Video • Post treatment

25. The Clinical Service Upper Limb Clinic

26. CONSULTANT + RESEARCH OT • Play based assessment • Spontaneous bimanual function • Directed bimanual function • ADL • Goniometry • Shoulder, elbow, wrist, fingers • Active, passive, catch • Orthotic Review • Treatment decision making • BTX A • Goal orientated • Functional • Orthoses • Range of movement • Dyskinesia • Evaluation post procedure • Therapy questionnaire • Parental reporting • Clinical re-assessment.

27. The Upper Limb Trial

28. Adolescent without Hemiplegic CP Adolescent with Hemiplegic Cerebral Palsy

29. Heteronymous reflexes Alpha motoneuron Gamma motoneuron x x Botulinum toxin Adults Babies Cerebral palsy O’Sullivan et al J Physiol 1991; Brain 1998 Pearse et al in preparation Pearse et al in preparation

31. 50 Study Participants 4 – 16 years old 27 Male / 23 Female 29 Left / 21 Right Hemiplegia Randomallocation by age, sex, paretic side & severity to: BoTN A Injections Placebo Injections &Child Centred Goals &Play Therapy &Child Centred Goals &Play Therapy

32. OUTLINE OF STUDY PROCEDURE

34. 6 Months

35. Duration of effect Botulinum Toxin P=0.02 P=0.025 NS Placebo NS NS P=0.035 P=0.023 P<0.001 P=0.047 P=0.025

36. CONCLUSION • Overall improvement seen in both groups • Significantly better outcome for Botulinum Toxin Treatment Group

37. This study was funded by The Children’s Foundation who received part funding from Ipsen With special thanks to the children and their families who took part in this study. Injection Injection Injection Therapy Therapy Therapy Months Months Months 0 0 0 3 3 3 6 6 6 Baseline Baseline Baseline Assessments Assessments Assessments

38. The Future • Lower Limb service • JOINT ORTHOPAEDIC AND ITB CLINICS • REGIONAL SPASTICITY NETWORK • Upper limb service • THERAPY GROUP CLINICS • RfPB funding – Computer technology • Development of play based assessment tools

39. Thank you for listening. Any Questions?