Occupational Therapy
Oral Medications
Intramuscular Injections

Occupational Therapy

Occupational Therapy recommendations are often, but not always, in conjunction with other intervention such as a spasticity reduction and/ or orthopedic surgery. The occupational therapy services in the community are often recommended to address upper extremity impairment, difficulty with self care skills (such as dressing and self feeding) and/or visual motor delay. The OT can also address any oral motor/feeding issues at the evaluation. Specific OT recommendations that can be made are as follows:

Splinting – Patients with range of motion (ROM) limitations may benefit from splinting such as a resting hand split or an elbow split to preserve the ROM available. Splints can be fabricated from a low temperature plastic or can be a soft splint made from neoprene.

Serial Casting - This is more commonly used in patients who need to gain ROM in the lower extremities but can also be used in the upper extremities, most often to gain elbow extension. Typically, a cast is placed on the arm at the maximum or near maximum position that can be achieved. The cast is changed weekly with the hope of increasing range of motion each week for approximately 3-4 weeks.

Constraint Induced Therapy – This involved restraining the strong arm for brief periods to encourage more voluntary and refined movement in the weaker arm for patients with hemiparesis. A cast or splint is often used to restrain the strong arm and the patient is provided with established activities to do with the weaker arm.

Therapeutic horseback riding – This is an excellent activity to improve balance and overall strength. Therapists will ride with a patient (to provide head and/or trunk control) or walk along side the patient who can sit independently on the horse.

Assistive Technology Evaluation – A referral for this type can assist in determining if wheelchair modifications, communication devices, or other adaptive equipment can be utilized to optimize function.

Oral Medications

All oral medications act systemically, that is, they affect the whole body and reduce spasticity or other abnormal movements throughout the body. They are usually mildly effective and usually more effective in young children than in older ones. No medication is effective for every individual.

Baclofen (Lioresal) - Baclofen is a medication quite similar to a chemical, GABA, that is deficient in people who have spasticity and is probably the most helpful and is used most often. Baclofen is usually given three times a day. When taken by mouth, a relatively small amount of baclofen gets into the spinal cord (where it needs to be to be effective. Baclofen is usually given in increasing doses up to a dose that depends on body size and weight. The medication is given in three divided doses and is increased until there is benefit, unacceptable side effects, or until a target dose is reached without benefit. The main side effect of oral baclofen is drowsiness. That side effect can be lessened if baclofen doses are started at low levels and increased slowly (e.g., every 5-14 days). Confusion and unsteadiness are less common side effects. Baclofen is not addicting and may be taken for years with minimal risk of it affecting other body organs. Baclofen is also effective in the treatment of dystonia.

Dantrolene (Dantrium) - Dantrolene is a medication used to treat spasticity. It is the only medication that acts on the muscles themselves rather than on the brain and for this reason, it causes less sedation than baclofen or diazepam although it may cause diarrhea, weakness, or a rash. Dantrolene may cause muscle weakness in high doses. Usual doses for spasticity range from 50-100 mg/day. Because Dantrolene occasionally causes liver damage, blood work is done approximately every six months to test liver function.

Tizanidine (Zanaflex) - Tizanidine is a relatively new medication that appears to be mildly effective but its use in children is often complicated by unacceptable drowsiness. Doses range from 4-24 mg/ day. Side effects include drowsiness, dizziness, and low blood pressure.

Diazepam (Valium) - Diazepam is mildly effective in reducing spasticity and athetosis. It also acts in the brain and also affects the release of GABA. Its effects last for far longer than the other medications. Unfortunately, diazepam is habituating, i.e., children who take it for several months get used to it and may require several months of slowly decreasing doses to get off of it.

Clonazepam (Klonopin) - Clonazepam is a medication similar to diazepam but has a shorted time of activity and is more easily discontinued. It may be given to treat dystonia or chorea. Doses range from 0.5 mg/twice daily to 2 mg three times a day.

Trihexiphenidyl (Artane) - This medication is frequently given to treat dystonia. It is given three times a day, beginning at perhaps 2 mg three times a day and increasing every 3-5 days up to 6-7 mg three times a day, and sometimes higher. Artane may cause dry mouth or urinary hesitancy but causes drowsiness infrequently.

L-dopa/Carbidopa (Sinemet) - This medication is often given briefly to children with dystonia for two reasons. First, there is a rare condition called dopa-responsive dystonia that may mimic CP and is dramatically improved by low doses of Sinemet. Secondly, some people with other forms of dystonia—including dystonic CP—are improved by Sinemet.

Intramuscular Injections

Intramuscular injections are given to patients who have spasticity or dystonia that is more severe in one or more areas and that is not satisfactorily treated by oral medications. The most common intramuscular medication is botulinum toxin; the most commonly used form of botulinum toxin is Botox. Recently, another form of botulinum toxin has become available, Myobloc; it is used mainly for children who do not respond to Botox injections. The medication can be injected directly into a spastic or dystonic muscle to decrease the tightness in those muscles. These medications weaken only the injected muscle and rarely cause any kind of central nervous system side effects.

Whenever intramuscular medications are used, they are usually injected in several different areas of the affected muscles. It is not unusual to inject 4-6 muscles at one time. Because of the multiple injections that are required, some type anesthetic is usually used, either a topical anesthetic to numb the skin over the muscles to be injected, or children can be given an anesthetic gas to sedate them for the 5 minutes or so needed for the injections.

Botox - Botox is a purified protein from the botulinum toxin. It comes frozen and is dissolved in saline then injected into the muscle through small needles. The amount to be given is determined by how tight the individual muscles are and by the weight of the child. Doses of 10-15 units/kilogram of body weight are commonly used and some experts use higher doses than that. The effects begin about 2-3 days after the botox is injected, hit a peak about 3 weeks later, and usually wear off in about 3 months. Injections are often repeated for 2-4 years. Botox has minimal side effects. Rarely, children may become unusually floppy for a few days or weeks after high doses of Botox.

Myobloc - Myobloc is a purified protein from a different form of botulinum toxin. It has been available for the past two years and there is less information on its use than for Botox. Myobloc comes already is a liquid form and is refrigerated until it is used. Doses of Myobloc are approximately 50 units of Myobloc to 1 unit of Botox. It can be given into any affected muscles and appears to have similar effectiveness and safety to Botox. The costs of the two medications are similar.

Alcohol and Phenol - These two medications were used fairly often before Botox and Myobloc were available but are used infrequently now. They are injected into spastic muscles near nerves and temporarily injure the muscle or nerve. Their effects last somewhat longer, 6-12 months. They may cause unpleasant sensations (feeling) in areas around the injected nerves.

Follow-up: After injections, physical therapists often perform serial casting and initiate therapy to increase range of motion. It is important for your therapist to follow-up with the team with regard to the effectiveness of the injections. Injections may be repeated several times, although effectiveness sometimes decreases after multiple injections.