Spasticity: orthopedic perspective

The orthopedic management of spasticity is based on the effects of this neurologic condition on the bones and tissues of the growing child. The goal of such intervention is to maximize function, reduce disability, and facilitate mobility. Goal-directed treatment plans are tailored for each patient and may include a combination of modalities such as physical and occupational therapy, casting, orthoses, and surgery. Physical and occupational therapy is emphasized up to 4 to 5 years of age, whereas surgery is best between 5 and 7 years of age. Education and psychosocial development should be emphasized beginning at age 7 years through adulthood, with surgery reserved for more involved cases of contracture or bony dysplasia. In adulthood, treatment should be focused on integration into society and maximizing functional independence. Although there are many undisputed benefits of therapy, no consensus exists regarding the most beneficial modality, the age group that would benefit most, or whether continued treatment is beneficial in adulthood. Whereas the use of serial casting and tone-reducing casts has lessened, lower extremity orthoses have gained widespread acceptance with improvements in design and fabrication and have been demonstrated to help restore normal heel-toe gait. Surgical techniques such as tendon lengthening, transfer, bony osteotomy, and joint fusion are time-honored techniques that continue to be refined with current advances in the use of computerized gait analysis for preoperative planning. Further research in long-term results and outcomes measurement will be necessary to fully assess the impact of current treatment.