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Movement therapies
Charlie Fairhurst
Evelina Children’s Hospital & Chailey Heritage
(Surrey under 14s Cricket Coach)
1
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• Introduction
• Movement therapy as part of holistic care
• Specific interventions
– General
– Focal
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Neurodisability - medical pathways
• Emergency care - medical stabilisation
• Diagnosis
• Long term Management ~
– Child ~ Quality of life • Think holistically
• Nutrition
• Seizures / Spasms
• Movement / Mobility / Posture
• Management - Family & interdisciplinary support ~ Quality of life
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Independence
Participation
Experience
Dependence
Core
Hierachy of
Clinical
Need
Developing a structure for review in Neurodisability
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PAIN FREE
COMFORT
SECURITY
ATTATCHMENT
No child can perform at
any level of ability unless
they have adequate
physical and
psychological comfort
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Basic Clinical
…needs met?
Psychological
Self identity
Physically
•minimise negative impact of
medical disorders seizures /
infections
•adequate nutrition?
Psychologically
•encourage self identity, whilst
acknowledging total
dependence
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Passive and
active
participation
Active
decision
making
Facilitating self control within
environments
•Home
•Play
•School
INPUT
•Communication
•Movement
•Education
•Physical needs
•Emotional needs
•Operational level
•Change of environment
Allowing the individual child to
make choice about their lives
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Treatment options in motor disorders
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Holistic Medical Management
• Motor difficulty – Movement and Posture
– Spasms
– Contractures
– Pain
• Co-morbidities – Seizures
– Chest
– Nutrition
– GI tract
9
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Principles of Motor Management
• Respond to the dynamic process encountered with growth to minimise secondary problems
• Respond to + and – effects of UMN syndrome
• Movement
• Posture
• Development
• Multidisciplinary approach
10
Adaptive approach
~ over time
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Upper Motor Neurone Syndrome
• Overactivation • Spasticity
– increased muscle tone – hyperreflexia – clonus – abnormal co-contraction
• Released flexor reflexes – mass synergy patterns
• Reduction in motor activity
• Loss of dexterity
• Weakness – inadequate force generation
– slow movements
• Loss of selective control
+ -
More amenable to
intervention
Usually more disabling but
less focussed on
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Dystonic Cerebral Palsy
• Confused terminology
– Dystonia / dyskinesis / athetosis / chorea
• ~10% of all Cerebral Palsy
– 67 % Term peri-natal hypoxic ischaemic encephalopathy
– 21% pre-natal or premature damage
– 12 % uncertain aetiology
• Atrophy and sclerosis of basal ganglia
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Therapy
• Function
• Neurodevelopmental practice
• Strength
• Stretch
• Uni vs Bilateral modalities
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Medical management of tone problems
General
Focal
Permanent Reversible
Oral
Therapy
Surgery
SDR
BTX-A
ITB DBS
ITB – Intrathecal Baclofen pumps
SDR – Selective Dorsal Rhizotomy
DBS – Deep Brain Stimulation
BTX-A – Botulinum Toxin A injections
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Spinal level
Locomotor Driving
System
Adaptive
system Equilibrium
system
BTX-A
SDR
Baclofen
Tizanidine
Antidystonic treatment
Oral
DBS
Dantrolene
Benzodiazepines
Anticonvulsants
ITB
Benzodiazepines
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Oral therapy Muscle relaxants • Baclofen
– Pre and Post synaptic GABA
– Use since 1970’s
– Poor lipid solubility, X cross Blood Brain Barrier ++
• Tizanidine – Adrenergic
– Drowsiness, Hypotension
• Clonazepam / Diazepam – Increase pre-synaptic inhibition spinal cord level
– Sedation
• Dantrolene – Prevents Calcium release from Sarcoplasmic reticulum
– Medicine of the devil
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Tone management
• Baclofen-GABA Agonist
-inhibits transmission at spinal level
-Reduces spasticity
-Depresses the central nervous system
-SE: Drowsiness and hypotonia, may lower the seizure threshold
• Dose 5mg Three times daily
– Increase to effect / side effect
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Oral therapy Movement modifiers – Anti-dystonic agents • Trihexyphenidyl
– Anticholinergic, basal ganglia – Medicine of first choice – High doses necessary – GI tract disturbance, Irritability, Urinary retention, Dry mouth & eyes
• Laevo-DOPA plus Carbidopa – Basal ganglia, increase L-DOPA – Insomnia, Nausea, Vomiting, Chorea
• Clonazepam – Central Nervous system – Drowsiness, Hypotension
• Carbamazepine • Dopamine depletor plus blocker
– Tetrabenazine – Depression ++, Drowsiness
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Trihexyphenidyl
• Drug most likely to have a favourable effect in non-progressive secondary Dystonia
• Start at 0.5 mg (infant), 1 mg (child) or 2 mg (adolescent) three times a day
• Increase by 0.5, 1 or 2mg per day each week until:
– It is effective
– Side effects occur
– Total daily dose of 9, 30 or 90 mg is reached
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Trihexyphenidyl .........................................................................
July 2007 – Oct 2011 153 children age 3-19 (69f, 84m) Start dose 0.5 mg (infant), 1 mg (child), 2 mg (adolescent) three times per day
Increase by 0.5, 1 or 2 mg per day each week until Maximum dose 1 mg/kg/day
134 Tolerated Dose
36 Stopped treatment
49 Continue low dose 2mg tds (no.=9), intermediate dose (no.=40)
6 Continue intermediate dose plus DOPA
43 Continue maximum dose
Beneficial effects in treatment group / 98
Longer tolerance of seating system 45 (46%)
COMFORT 57 (58%)
Improved oromotor skills / swallowing 25 (26%)
Reduced power of extensor thrust 31 (32%)
Improved saliva control 43 (44%)
Other - combined 97
Side effect in treatment group / 98
Transient agitation 37 (38%)
Loss of short term memory ?>7 (>7%)
Transient dyskinesis 13 (13%)
Constipation 20 (20%)
Urinary retention 5 (5%)
Blurred vision ?>8 (>8%)
Xerostomia – dry mouth 22 (22%)
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Laevodopa plus Carbidopa Start dose 1 mg / kg L-DOPA per day in four divided doses
Weekly increase 1 mg / kg Maximum dose 10 mg / kg, Continue for 3 months for therapeutic trial
October 1998 – October 2011
37 children, age 5-19 (10f, 25m)
8 stopped at low dose
• 3 Aggression
• 2 Depression
• 3 Chorea
29 that had L-DOPA for more than 3 months
13 Stopped – insufficient benefit
8 Continued mono-therapy
6 Continued plus Trihexyphenidyl
Benefits / 29
Improved swallowing 11
Reduced dysarthria 14
Reduced extensor spasm 12
Reduced upper limb dystonia 9
Better tolerance equipment 16
Other 6
None 7
Side effects / 29
Nausea 13
Altered liver profile 4
Aggression 3
Sleepiness 0
Insomnia 0
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Spinal level
Locomotor Driving
System
Adaptive
system Equilibrium
system
BTX-A
SDR
Baclofen
Tizanidine
Antidystonic treatment
Oral
DBS
Dantrolene
Benzodiazepines
Anticonvulsants
ITB
Benzodiazepines
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Botulinum Toxin type A
Medico legal and medico-economic factors
Limited license – accepted practice
Integrated therapy & Common indications
Doseage and safety
Assessment, administration, re-evaluation, continuation and dis-continuation
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•Benefits vs Risks – Reduced spasticity / spasms vs weakness
•Ambulant vs Non-ambulant children – long term studies??
•vs Pain – Significant benefit for up to six months
•Functional benefit – Posture, ADL, QOL
•Upper limb •Neck & Spine •Saliva Control
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Botulinum Toxin in Hip spasticity
• 6 months
• 27 new children, adolescents in pain
• PPP pre average 39 (range 24 – 59)
• Functional challenges – Toileting
– Cleanliness
– Dressing
– Sleeping
• USS guided injections to – Iliopsoas, Medial Hamstrings, Adductor Magnii
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Botulinum Toxin in Hip spasticity
• 6 months
• 27 new children, adolescents
• PPP pre average 39 (range 24 – 59)
• PPP 1 month post average 9 (range 0 – 23)
• Functional improvements
– Toileting
– Cleanliness
– Dressing
– Sleeping
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PRE 1 MONTH POST
60
30
10
20
40
50
Paediatric Pain
Profile Scores
Pre and Post targeted
Botulinum Toxin
Injections SCORE
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UK Audit 2010 - 11
• TOTAL 60 +15
• South West 3+1
• South Thames 9+4
• North Thames 7
• Oxford and Anglia 8+3
• Trent / East Midlands 2+2
• West Midlands 8+2
• North West 4
• Northern and Yorkshire 7+2
• Wales 2+1
• Scotland 5
• Northern Ireland 2
• Ireland 3 32
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Injection Numbers in 2010 Population 1 - 16
• North Thames 811 1.924m
• South Thames 782 1.588m
• South West 426 0.927m
• West Midlands 546 1.067m
• Oxford and Anglia 485 0.724m
• East Midlands / Trent 335 0.822m
• North West 430 1.338m
• North East and Yorkshire 507 1.460m
• Wales 115 0.567m
• Scotland 214 0.929m
• Ireland 224 1.246m
• TOTAL 4875 12.592m
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34
Maximum doses used
Botox - iu ~
100 = 1 4/kg = 2 200 = 9 6/kg = 1 300 = 1 8/kg = 3 350 = 1 10/kg = 3 400 = 22 12/kg = 14 600 = 1 13/kg = 1 700 = 1 15/kg = 2 800 = 1 16/kg = 4 1000 = 1 18/kg = 1
25/kg = 6 27/kg = 1
Dysport - iu ~
20/kg = 1
900 = 1 25/kg = 2
1000 = 11 30/kg = 11
1200 = 5 35/kg = 4
2000 = 1 40/kg = 1
50/kg = 1
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Injection sites • Upper limb 39 / 60
• Shoulder 29
• Elbow 39
• Wrist 36
• Fingers / thumb 32 / 31
• Lower limb 58 / 60 • Hips 56
• Hamstrings 53
• Gastroc-Soleus 56
• Small muscles 39
• Neck / Back 17 / 60
• Saliva glands 12 / 60
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Spinal level
Locomotor Driving
System
Adaptive
system Equilibrium
system
BTX-A
SDR
Baclofen
Tizanidine
Antidystonic treatment
Oral
DBS
Dantrolene
Benzodiazepines
Anticonvulsants
ITB
Benzodiazepines
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Movement therapies
Invasive techniques
Selective Dorsal (Posterior) Rhizotomy
Intrathecal Baclofen pumps
Deep Brain Stimulation
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Selective Dorsal Rhizotomy
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UK & Ireland centres SDR
• Robert Jones and Agnes Hunt, Oswestry
• Bristol
• Nottingham
• St Louis
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Intrathecal Baclofen Combination of Dystonia and
Hypertonia
AACPDM 2000 – 25 trials
17 trials showed benefits
•Movement, posture
•Pain, spasms
•ADL, QOL
•Reduced Orthopaedic
intervention
ITB withdrawal syndrome
•Increasing spasms, seizures and pain
•Agitation, Hallucinations, Itching, Hyperthermia
Infection
•Acute, Long term
Overdose – Hypotonia, drowsiness, respiratory depression
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ITB UK & Ireland centres • Nottingham
• Sheffield
• Evelina Children’s Hospital
• Bristol
• Birmingham
• Alder Hey
• Newcastle
• Edinburgh
• Dundee
• Dublin
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DBS UK & Ireland
• Evelina Children’s Hospital
• Bristol
• Oxford
• Edinburgh
44
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Choices, choices, choices….. -Spasticity Dystonia Both
-Tightness Weakness Co-ordination
-Focal General Problem
-Functional difficulties Co-morbidities
-Hopes and expectations Goal setting
-Health Economics Experience Availability