Indications for treatment
Consider treating spasticity when it causes loss of function or produces contractures, deformities, pressure sores, or pain. Additional indications include difficulty in positioning or caring for the total body involved child. Even though a wide range of treatments exist, none of them is fully satisfactory. Unwanted side effects limit the use of certain modalities. Some children do not respond to any of the antispasticity measures. The success of treatment depends on having specific goals in treatment, choosing the correct method according to the child’s problem and monitoring for side effects and complications.

• Goals of spasticity treatment
  • Increase function
  • to perform better in activities
  • of daily living
• to walk better
• Increase sitting ability and balance
• Prevent deformity & decrease contractures
• Pain relief
• Improve hygiene and patient care

Treatment methods
Treatment options are divided into reversible and permanent (surgical) procedures.

• Physiotherapy
  • Positioning
  • Exercises (Stretching, Neurofacilitation)
  • Electrostimulation
• Splinting & Casting
• Oral medications
  • Baclofen
  • Diazepam
  • Clonazepam
  • Dantrolene
  • Tizanidine
• Intrathecal medications
  • Baclofen
  • Morphine
  • Clonidine
• Neuromuscular blocks
  • Local anesthetics
  • Phenol
  • Botulinum toxin
• Orthopedic surgery
• Selective dorsal rhizotomy

They can also be classified as systemic or local treatments. All treatment procedures aim to modulate the stretch reflex. In mild spasticity, basic measures such as positioning, exercises and bracing may be sufficient whereas in more severe cases, interventions can be more invasive. Often, treatments are combined to decrease side effects and to improve outcome.

Physiotherapy
Physiotherapy is a fundamental part of spasticity management. Muscle overactivity produces muscle shortening and muscle shortening increases spindle sensitivity. Muscle contracture and stretch sensitive muscle overactivity are intertwined. Therefore physical treatments aimed at lengthening the overactive muscles are fundamental. Address both shortening and overactivity. Consider applying various techniques such as positioning, ice, and exercises for these purposes. Positioning Position the child to stretch the spastic muscles and decrease the sensitivity of the stretch reflex and the brain stem reflexes that trigger spasticity. The therapists should teach these positions to the family so that the child lies and sits this way most of the time at home. Head supports may improve tone in the trunk muscles by providing a sense of safety and inhibiting the tonic neck reflexes. Advise use of the tailor-sitting position to reduce adductor spasticity. Good seating provides a stable platform and facilitates good upper extremity function. Stretching exercises Stretching muscles may prevent contractures and promote muscle growth. Spasticity decreases with slow and continuous stretching. This effect lasts from 30 minutes to 2 hours. Use stretching exercises before bracing and serial casting to obtain the necessary joint position.

Neurofacilitation techniques Most neurofacilitation techniques are used to reduce muscle tone. With the Bobath method, the therapist positions the child in reflex inhibitor positions and provides kinesthetic stimulation to inhibit the primitive reflexes and elicit advanced postural reactions to normalize muscle tone. With the Vojta method, different positions and proprioceptive stimulation are used for the same effect. Tone reduction lasts for a relatively short period of time with both methods.

Inhibitive (Tone Reducing) Casting and Bracing
Muscle relaxation after stretching exercises lasts for a short period of time. For longer duration the stretch on the muscle should be maintained for several hours every day. This is possible with the use of rigid splints or serial casting. The effects are maximal if the cast or the splint is applied after the muscle is relaxed. The tone-reducing effect of casts and splints is controversial. Some think that casts decrease muscle tone by creating atrophy in the already weak spastic muscle. Casts also cause pressure sores in children who are malnourished and have severe spasticity. Patient compliance may be poor because of difficulties of living with the cast. Consider casting as an adjunct to treatment with local antispastic medications in the young diplegic or hemiplegic child with severe spasticity interfering with ambulation to delay orthopaedic surgery. At present, the most common methods of spasticity management in cases of CP are oral medications, botulinum toxin, phenol or orthopaedic surgery.