Spasticity and Movement Disorders Clinic
The Spasticity and Movement Disorders Clinic at the Children's Hospital of Pittsburgh is made up of a team of pediatric medical professionals who specialize in the comprehensive, multidisciplinary evaluation and treatment of children and young adults with spasticity and other movement disorders such as dystonia, chorea, athetosis, and tremor. The purpose of the clinic is to determine whether or not a patient would benefit from treatment with oral medications, intrathecal baclofen, selective posterior rhizotomy, intramuscular botox injections, deep brain stimulation or other therapies. Currently, we have over 1000 patients being followed by the team. Approximately 150 new patients are evaluated in the clinic each year.
The Spasticity and Movement Disorders Center was founded by A. Leland Albright, MD, in 1986. He was the first investigator in the United States to be approved by the Federal Drug Administration to study the use of intrathecal baclofen. He was also the first to perform deep brain stimulation for tremor dystonia resulting from cerebral palsy.
Elizabeth Tyler-Kabara, MD, PhD, performs these procedures as well as selective posterior rhizotomies, intramuscular botulinium injections and selective peripheral nerve fasiculotemies.
Diagnosis and Evaluation
The clinic is held every Wednesday morning beginning at 8:30 a.m. at the Children's Hospital of Pittsburgh. Patients are evaluated individually by the team members. Each specialist performs a separate evaluation which gives the team several different perspectives and helps them when deciding on a treatment recommendation. Since all of the areas are equally important to the success of treatment, it is necessary to be as comprehensive as possible. It is important that you bring any scans, x-rays, braces, walkers, or canes for the evaluation.
After the evaluation by the team, they meet in a conference to discuss their findings and to decide on the recommendations. Because of the time spent performing evaluations and discussing their recommendations, you can expect to be in the clinic until about 1:30 pm. Before you leave clinic, a staff member will discuss the recommended treatment with you.
How to Make an Appointment
You can make an appointment to be seen in the Spasticity and Movement Disorder Clinic by contacting our clinic at (412) 692-5520.
If you are from outside our geographic area and you feel that you or your child may be a candidate for the Spasticity and Movement Disorders Clinic, we would appreciate it if you would send a summary from your physical or occupational therapist along with a 5-10 minute video of you or your child showing them lying, sitting, standing and walking viewed from the front, the side and the back. Video should be mailed to:
Elizabeth Tyler-Kabara, MD, PhD
Division of Pediatric Neurosurgery
Children's Hospital of Pittsburgh of UPMC
4401 Penn Avenue
Faculty Pavilion, Suite 4000
Pittsburgh, PA 15224
What are Spasticity, Dystonia, Chorea, and Athetosis?
Spasticity is an involuntary muscle tightness and stiffness that occurs in about two-thirds of people with cerebral palsy (CP) and in many who suffer severe head injuries. The medical definition of dystonia is a velocity-dependent, increased resistance to passive muscle stretch. In other words, when a muscle affected by spasticity is stretched by someone else, it is harder to move the muscle than normal, and the faster one pushes, the harder the muscle is to move.
Dystonia is the second most common movement disorder. It is characterized by sustained muscle contractions that result in twisting movements and abnormal postures and is present in 25-35% of people with CP. It may begin in childhood, adolescence or adulthood, and may affect only one region of the body, such as the neck, in which case it is called focal dystonia. It can occur in adjacent body regions (segmental dystonia), and one side of the body (hemidystonia) or all of the body (generalized dystonia). Dystonia may also occur after head injuries or as an isolated problem.
Athetosis is defined as slow, writhing motions of the fingers and hands and occurs in approximately 5% of people with CP. Athetosis was used commonly a few years ago, but now, many of the people who were previously diagnosed as having athetosis are considered to have dystonia. We believe the two disorders are different, in that athetosis affects muscles of the fingers, hands, and around the mouth, causing slow, twisting, writhing motions that are more continuous than dystonic movements.
Chorea(pronounced "korea") is an involuntary abrupt, rapid, brief, and unsustained irregular movement and is sometimes described as "dance-like". Chorea occurs in 5% of people with CP.
Ataxia is an abnormality of coordination and particularly affects walking; gait is typically very unsteady.
It is important to remember that people may have more than one movement disorder at one time; the combination of spasticity and dystonia is particularly common.
Why do These Problems Occur - Pathophysiology?
Muscle tone—the state of muscle contraction—is controlled by two factors: inhibitory (relaxing) signals combing down from the brain into the spinal cord, causing the release of a chemical, GABA, which make the muscles relax, and excitatory stimulating) signals coming from the muscles into the spinal cord, telling themselves to contract (tighten). If the balance between those two is normal, muscle tone is normal.
Spasticity is caused by damage to parts of the brain that send the messages for GABA to be released. The damage may occur anywhere along the pathway, from the brain to the brainstem to the spinal cord. The end result is the same: deficiency of GABA and a relative excess of excitatory impulses.
The cause of dystonia is not understood nearly as well as the cause of spasticity. It is thought to be due to damage to the basal ganglia, deep structures in the brain that adjust the amount of movement that occurs when people tell a muscle to move. The cause of athetosis is probably similar.
Chorea is due to damage to a different region of the basal ganglia, so that output from a structure called the internal globus pallidus is less than normal.
One of the main things the team tries to determine is what the goals of the family and patient are. Those goals often affect which treatment is recommended. The team also tries hard to make sure the family understands the reason a particular treatment is recommended—what outcomes are hoped for.
The main indications for treating movement disorders include:
- to facilitate care,
- to improve function,
- to retard or prevent the development of contractures, and occasionally, to improve pain.
If function is to be improved, the team evaluates the child for muscle tone, trunk strength, underlying muscle strength, motivation and ability to comply with therapy. Functional improvements often include improved communication, swallowing, activities of daily living, and mobility.
If the goal of treatment is to facilitate care, the team looks at how difficult it is to dress, toilet, feed, position, and transfer the child. If these activities of daily living will be made easier for the caregiver, treatment would be considered.
It is important to realize that some treatment is recommended for almost all patients but that surgical treatment is not recommended for everyone. Some are too young or too small, some can be effectively treated by oral medications or intramuscular injections. Occasionally, it is not clear which treatment would be most appropriate; in that case, the team often asks to re-evaluate the child after a specific time period.
For more information on the Spasticity and Movement Disorder Clinic, please visit the clinic's webpages on the Children's Hospital of Pittsburgh website.