Multiple micronutrient supplementation increases the growth of Mexican infants1–4 Juan A Rivera, Teresita González-Cossío, Mario Flores, Minerva Romero, Marta Rivera, Martha M Téllez-Rojo,Jorge L Rosado, and Kenneth H Brown ABSTRACT many studies about the effect of individual micronutrients on Background: The role of single micronutrient deficiencies in the etiology of growth retard
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Microsoft word - famguide.docDIRECTOR, PEDIATRIC PHYSICAL MEDICINE AND REHABILITATION Table of Contents
II. Physical Therapy, Occupational Therapy, Speech Therapy I. Introduction
The information in this booklet has been compiled to help families understand the different
treatments or combinations of treatments that may be suggested for management of your child’s
spasticity or dystonia.
Spasticity in children with brain injury, cerebral palsy or spinal cord injury is very common but
often difficult to treat. In its most general term, spasticity is “increased resistance to passive
movement or muscle stretch, which can interfere with mobility, self-care, positioning, and
ultimately lead to joint contractures. This occurs when there is an illness or injury which affects
the brain, brain stem, or some area of the spinal cord. Individuals who have spasticity have
increased reflexes and clonus ( a rapid up-and-down movement about a joint in response to
muscle stretch). Dystonia is a type of movement disorder that is characterized by intermittent
“posturing”. Many children have a combination of spasticity and dystonia. For the remainder of
this booklet, we will use spasticity to describe the movement difficulty, with the understanding
that dystonia may also be a component.
There are numerous ways to treat spasticity. These include stretching, strengthening, orthotics,
casting, therapeutic electrical stimulation, nerve or muscle blocks, medications, tendon
lengthening and other orthopedic procedures, and dorsal rhizotomy. The goal of these treatments
is to increase range of motion of a joint and decrease spasticity. This may help to increase
Consider discussing the following ideas with your physician when considering treatment for
1. How do we decide which treatment course to follow?
2. Can the treatment be expected to help decrease spasticity?
3. What are the expectations and probable outcome?
4. Do the potential benefits outweigh the risks?
5. What will be the therapy program after treatment?
6. How will treatment effects be measured?
Spasticity is a problem when it interferes with function including movement, hygiene, or
positioning. We will use a circle as our model for treating spasticity, with different parts of the
circle representing different treatment options. We can move around the circle to use different
options at various points in a child’s growth and development. A combination of treatment
options can be used at the same time.
TREATMENT OPTIONS FOR SPASTICITY
II. Physical Therapy, Occupational Therapy, and Speech Therapy
Recommendations for therapy are based on a child’s current level of functioning. Not all
children need each type of therapy. Therapy recommendations will change over time.
Furthermore, the goals of each specific therapy will change as the child’s functional goals and
movement patterns change.
A. Physical Therapy
Physical therapy programs are designed to help a child obtain maximal functional independence
in the home, school, and community. When muscles are “spastic”, there is an imbalance of the
muscle pull around a joint. This increases a child’s risk of developing a joint deformity or a
muscle contracture. Physical therapy is prescribed to help improve gross motor function and
maintain range of motion to prevent joint deformities and muscle contractures.
There are several different approaches of physical therapy for children. Many therapists use a
combination of philosophies. Examples of different therapy models include neurodevelopmental
therapy (NDT), Proprioceptive Neuromuscular Facilitation (PNF), conductive education, and
manual therapy (myofascial release and craniosacral therapy). Hippotherapy, or horse back
riding, can help a child increase balance and improve trunk control. Aquatic therapy can help
promote more typical patterns of movement that are often affected by gravity.
Each child should have a home exercise program. It is essential for you to be aware of the goals
of therapy. Your child only spends a few hours a week with a therapist. However, your child
spends the rest of his/her time with you. Therefore, if you can learn to carry out the techniques of
therapy, therapy will offer greater benefits for your child. Parents can learn ways to increase
and/or maintain range of motion in muscles, position a child, supervise exercises to strengthen
muscle groups, and provide support to a child to improve functional movement.
Physical therapists also help design adaptive equipment including orthotics, seating systems and
wheelchairs. There are also different modalities which physical therapists can use to help relax or
strengthen muscles to improve function. Again, it is important for all individuals working with a
child to be able to incorporate the goals of therapy into activities of daily living.
B. Occupational Therapy
Occupational therapists work with children in many different ways. They work to help improve
upper extremity function, improve trunk balance, increase independence with activities of daily
living, improve visual perceptual skills, and provide appropriate adaptive equipment to maximize
independence. Occupational therapists often work together with other disciplines to incorporate
therapy goals into a child’s regular activities.
When a child has spasticity in his/her arms or hands, it can interfere with coordination as well as
function. A child may have low tone in his or her trunk or neck which interferes even more with
the child’s ability to use his or her hands to play with objects in the environment.
The occupational therapist must be able to evaluate each child’s individual needs and develop a
program to help improve head and trunk stability as well as fine motor skills. There are also
times when adaptive equipment such as hand splints or forearm splints may be needed to
improve hand function. It is the occupational therapist who would make these splints.
Many children receive occupational therapy both in school and at home. Usually, the
occupational therapy which a child receives in school focuses more on school related activities.
If a child needs help increasing independence with activities of daily living such as hygiene,
dressing, or bathing, additional therapy might be needed for these skills. Sometimes, school
therapists do not feel as though they can address functional skills. Again, it is important for
parents to become familiar with the goals of a child’s occupational therapy program.
Recommendations made by a therapist to adapt different areas of the home and/or school will be
important to allow the child to gain greater functional independence.
C. Speech Therapy
Speech therapists work on a variety of activities including increasing oral motor skills, cognitive
skills, and communication skills. An additional focus area is feeding skills. Eating is a complex
activity. A child should be able to take food off a spoon or fork, then chew and swallow it. If this
can not be done safely, a child may need a special feeding tube called a gastrostomy tube.
Therapy can focus on improving oral motor skills for swallowing and communication.
There are several different components involved in eating/swallowing. A speech therapist can
work together with an occupational therapist and/or physical therapist to maximize independence
with eating. The speech therapist will focus on the activity of the muscles around the mouth,
tongue and oropharynx. The occupational therapist works on fine motor skills involved with
eating. The physical therapist can work on positioning and trunk control. The goal is to enable
the child to eat safely without the risk of getting food in the lungs (aspiration). Again, it is
important for family members to learn the goals of a child’s speech therapy program.
Speech and language pathologists also work on improving strategies for learning and increasing
social and communication skills. Many times a child with muscle imbalance in the trunk or neck
will have trouble breathing or speaking. If a child is able to breath more easily, speaking may
improve. Also if a child’s trunk is positioned better, swallowing will be easier.
Children who have muscle imbalance secondary to spasticity may need adapted equipment to
help maintain range of motion, prevent joint deformity, and maximize functional independence.
This equipment can include soft body jackets, special seating, or special orthotics for the hands
or the feet.
A. Equipment that Improves Positioning
There are many ways that equipment can be adapted to help a child sit in a better position.
Controlling the position of a child’s pelvis, knees, and ankles can help decrease arching, increase
head control and shoulder stability, and improve functional hand use. Children may need
different types of equipment at different times during their growth and development. Again, the
goal is to increase control of movement and manipulation of objects in the environment. Some
examples of equipment that can help improve positioning are:
Orthotics are designed to help provide support to weak muscles and minimize the risk of joint
deformity. There are a variety of orthotics made from a number of different materials. The goal
is to use an orthotic which can give support depending on a child’s pattern of movement, avoid
skin breakdown, and be comfortable. If areas of the skin become red, this indicates that the
orthotic may not be fitting appropriately, especially if the redness lasts more than half an hour
after removing the orthotic.
C. Serial Casts to Gain Range of Motion
Serial casts can either be used for the arms or the legs. The goal is to maintain or increase range
of motion of a muscle, tendon, or joint. The casts provide a sustained stretch across the joint.
Prolonged stretch can help muscles relax. The cast may also help “soften” tendons.
Serial casts are normally changed one time per week. The number of total weeks of casting
varies depending on the need of each child. The goal is to slowly gain more joint range without
causing significant discomfort to the child.
D. Inhibitive Casts to Improve Function
Inhibitive casts are used to increase function more than to improve range of motion. Sometimes,
inhibitive casts will be used to “give more information” (proprioception) to the ankle joint or the
foot in order to prevent a child from using “reflex patterns” of movement. They are often utilized
when a child with muscle imbalance is learning to walk. They can give better proprioceptive
input to the foot when compared to the AFO since they are heavier and can have special features
built in to them.
For example, inhibitive foot plates can be built into the base of each cast. The inhibitive foot
plates apply pressure to different areas of the foot to give better proprioceptive input to the joint
which inhibits reflex patterns of movement. Often times, we will use inhibitive casts prior to
prescribing orthotics, depending on a child’s function.
Medications might only be used for “short periods” of time. Some medications require a several
week dose advancement schedule in order to get an appropriate level of response. The dose of
medication is increased slowly to prevent side effects such as sleepiness. Occasionally,
medications will require monitoring bloodwork for certain side effects.
Baclofen works at the level of the spinal cord on the interneuronal connections Side effects are minimal but do include sedation and possibly problems with swallowing. This medication must not be stopped suddenly. It must be decreased
Valium acts in the upper part of the central nervous system to enhance the normal inhibitory effects of the neurotransmitter GABA. Side effects include sedation, memory impairment, and possible respiratory Clonazepam (Klonopin) - Effects are similar to Valium.
Dantrium works directly on the muscle at the level of the muscle fiber to block calcium release which is necessary for muscle contractions. Dantrium makes it difficult for spastic muscles to maximally tighten. Side effects include sedation and possible liver problems. As a result, blood tests are needed to monitor liver function. Approximately 1% of people on Dantrolene experience liver dysfunction. Lab work needs to be done 2 to 4 times per year to Tizanidine (Zaniflex)
Tizanidine is a medication, which was approved for use in 1996 for the treatment of adults with spasticity from spinal cord injuries and multiple sclerosis. The safety of the drug for children has not been established. However, the company that manufacturers the drug states that they feel that the medication is safe for children. Dosing recommendations for children are outlined by the manufacturer.
V. Nerve and Muscle Blocks
A. Botox Injections (Botulinum type A toxin)
Children who benefit most from Botox are those who are too young for surgery or for whom
surgery is not yet warranted. Botox injections can provide an opportunity to evaluate the child’s
readiness for more permanent orthopedic procedures. In some cases, injections can provide
enough spasticity control that surgery can be avoided.
Botox injections can help improve a child’s ability to walk or use their hands and allow for a
better fitting orthotics by reducing spasticity. Therapists can take advantage of the time when an
overly powerful muscle is weakened to work on strengthening the muscle on the opposite side of
the joint (antagonist). Sometimes, casting of the involved extremity is done after the injection to
increase the stretch of the tight muscle.
When injected into the muscle, Botox interferes with the release of a chemical, acetylcholine, at
the junction of the muscle and nerve. This partially interrupts muscle contraction making the
muscle temporarily weaker. This becomes evident two to ten days after treatment and lasts
approximately 3 to 6 months.
Botox is currently being used to treat spasticity due to multiple sclerosis, head injury, stroke and
spinal cord injury. It has been used to relieve movement disorders of the head and neck, such as
torticollis. Most recently, botulinum toxin has been used successfully to treat spasticity in
children due to the muscle imbalances caused by cerebral palsy. “Dynamic deformities”
unresponsive to other treatments, may improve following Botox, delaying or preventing the need
for surgery or orthotics.
Botox is injected directly into the spastic muscle where it diffuses only a short distance. It is
dosed according to total body weight and injections can be repeated after three months. Up to
10% of patients already have antibodies to botulinum toxin and may not respond to the
injections. Children should not be on an aminoglycoside antibiotic when Botox is injected as it
may also interfere with response to the Botox.
Botulinum toxin is injected through a very small needle much like an immunization, and side
effects are few. Local tenderness can occur but is related to the volume administered.
Occasionally there may be a skin irritation or rash. Sometimes a special needle is used which
electrically localizes the muscle where the Botox is needed. This medication can be injected in a
clinic setting with the option of using a topical anesthetic for the skin and/or mild sedation.
The reported side effects of this procedure include pain at the injection site and, in some cases,
generalized fatigue of short duration. This medication is felt to be very safe at the therapeutic
The muscle relaxation resulting from Botox can provide comfort and ease of care for those
patients in whom spasticity causes pain or difficulty with hygiene.
The effects of botulinum toxin are seen two days to ten days after the injection and the If you choose Botox as the method to decrease the spasticity, please read the following: We will use a topical cream to numb the area of the injection. This takes If we are doing several injections, without anesthesia, we may need to give another medicine to make the procedure easier for your child to tolerate. Therefore, please don't eat or drink anything two hours before your We will need to see you back in clinic in one week after your injection to start
Overall, Botox provides a non-operative way to manage spasticity in a relatively pain- and risk-
B. Phenol Injections
Phenol is an alcohol based drug which partially dissolves the “covering of the nerves” (myelin),
slowing the messages to muscle. Myelin will typically re-coat the nerve after 4-12 months. For
this reason, phenol blocks are considered temporary, and can be redone. Phenol is currently
being used to treat spasticity due to multiple sclerosis, head injury, strokes, spinal cord injury and
cerebral palsy. “Dynamic deformities” unresponsive to other treatments, may improve following
phenol, delaying or preventing the need for surgery or orthotics.
Phenol is injected around the “motorpoint,” where a nerve branch enters the muscle. The
motorpoint is localized using a small needle which is attached to an electrical simulator. This
produces small muscle contractions letting physicians know they are in the correct place. The
localization process requires the patient to be still. The injections may cause a mild burning
sensation. For this reason, young children may tolerate the procedure better if it is done in day
surgery with a general anesthetic. The procedure generally takes between 10 and 20 minutes, so
the anesthetic time is brief. For older patients, the injections can be done in a clinic setting, using
a topical anesthetic to numb the skin, with mild sedation if needed. The effects of phenol are
Side effects of phenol can be mild bruising where the medicine is injected, but this generally
resolves after a few days. Transient numbness or tingling can also occur if the drug is injected
near a sensory nerve. Also, a muscle pull can occur if the treated muscles are not given time to
slowly stretch out. Aggressive therapy is not recommended for a few days after the blocks, to
avoid this problem.
effects can occur Effects seen immediately
Phenol neurolysis or “blocks” have been used for many years for the purpose of increasing range
of motion, and to decrease rigidity and spasms, and continue to be very effective in reducing
spasticity, particularly in the lower extremities.
Muscles most commonly treated with phenol blocks are the hip adductors and the hamstrings. If
they are too tight, they can cause significant problems with gait and seating. Phenol dosing is not
based on a child’s weight, so it may be more effective to use in large muscle groups than Botox,
which has a maximum dose based on a child’s weight. These two drugs are often used in
combination for more effective treatment.
Children who benefit most from neurolytic agents are those who are too young for surgery or for
whom surgery is not yet warranted. Phenol neurolysis can provide an opportunity to evaluate the
child’s readiness for more permanent orthopaedic procedures. In some cases, injections can
provide enough spasticity control that surgery is not necessary.
Phenol blocks can help improve a child’s ambulation and allow for a better fitting orthotic by
reducing spasticity. Therapists can take advantage of the time when an overly powerful muscle is
weakened, to work on strengthening the antagonistic muscles. Sometimes, casting of the
involved extremity is done at the same time or shortly after an injection to increase the stretch on
VI. Post Block Follow-up
If your child has had anesthesia, there are certain things that need to be monitored after the
procedure is completed. Your child does not have to stay in bed. There are certain exercises that
need to be limited for one week if your child has had phenol injections. Otherwise, with the
Botox, there are no precautions.
After a child has anesthesia, it is recommended that small amounts of ginger ale, ice pops, Jello,
apple juice, or soup with crackers be given. On the day after the procedure, the child may go
back to his or her regular diet.
Phenol injections can cause some discomfort. For the first 24 hours after the injection, a child
may use Tylenol (acetaminophen) or Motrin (ibuprofen) for the discomfort. Children who have
had Botox injections, usually have minimal pain. However, if there is some discomfort, we
recommend using Tylenol.
In general, any child who has had anesthesia may be irritable for a while. It is advisable to plan
quiet activities. However, as a child feels better, he or she may return to normal activities.
If you have any concerns after the injections, call your physician. Look for any swelling, redness,
or drainage at the injection sites. If a child has more than mild discomfort, this is another reason
to call. If there is any color change, coolness, numbness, swelling, or tingling of the arm or leg,
please let the doctor know.
A child’s physical therapist or occupational therapist is encouraged to call the physician to
further discuss program goals. If the gastroc muscles have been injected with Botox, we will
often begin serial casting one week after the blocks. This depends on a child’s response. It is
recommended that all children follow up with the physician who did the blocks one to two weeks
after completion of the injections.
VII. Therapeutic Electrical Stimulation
Therapeutic Electrical Stimulation (TES) stimulates muscle growth to diminish the effects of
spasticity. TES involves the use of nighttime low level electrical stimulation to produce muscle
growth. The stimulus is adjusted so that a muscle contraction is not produced.
The current is delivered through the skin using water activated adhesive electrodes. These
electrodes are placed over the weak and non-spastic antagonist muscles. All of the therapy is
done at home, at night while the child sleeps.
The exact mechanism of action of TES is not known. It is possible that TES improves blood flow
to stimulate local muscle growth. TES may capitalize on the natural growth and repair function
of sleep. Another potential benefit of TES is decreasing spasticity during some phases of sleep.
In this way the stimulus can be given to the non-spastic antagonist muscle without initiating a co-
To stimulate end- Growth in muscle Mild skin Electrical
Acupuncture is a method of encouraging the body to promote natural healing and to improve
functioning. It is done by inserting needles and applying heat or electrical stimulation at very
precise points on the body. This is considered an alternative treatment.
According to classical Chinese teachings, there are channels of energy that run in regular
patterns through the body and over its surface. The energy is perceived to be like a river, flowing
through the body to nourish the tissues. If there is an obstruction in the movement of these
“energy rivers”, a “dam” develops that backs up the flow in one part of the body and restricts it
in others. The philosophy behind acupuncture is that by needling the acupuncture points, the
nervous system is stimulated to release chemicals in the muscles, spinal cord, and brain. These
chemicals can trigger the release of other chemicals and hormones which influence the body’s
own internal regulating system.
The improved energy and biochemical balance produced by acupuncture results in stimulating
the body’s natural healing abilities. In some cases surface electrodes can be used instead of
The number of treatments needed for a condition differs for every individual. If a condition is
long-standing, one treatment a week for several months may be recommended.
As energy is redirected in the body, internal chemicals and hormones are stimulated and healing
begins. Occasionally, symptoms may worsen for a few days. This should not be a concern as it is
simply an indication that the acupuncture is starting to work. It is also quite common with the
first few treatments that a sensation of deep relaxation or mild disorientation may immediately
follow the treatment. These pass within a short time.
Acupuncture treatments can be given at the same time as other techniques are being used. It is
important that both the physician and the person who is doing the acupuncture know everything
that is happening with the child so that the maximum benefits can be achieved from the
On the day of treatment
To enhance the value of a treatment session, there are a few guidelines which need to be
• The child should not eat an unusually large meal immediately both before or after treatment.
• Do not over-exercise within six hours before or after treatment.
• Plan activities so that after the treatment the child can rest or at least not have to be working
• Continue to take any prescription medicines as directed by your regular doctor.
Since acupuncture is considered an alternative treatment, some insurance companies will cover
acupuncture costs but many insurance companies do not. Each health policy should be reviewed
to determine if there are benefits for acupuncture treatment.
IX. Intrathecal Baclofen Pump
Baclofen was introduced initially as a drug to treat spasticity. It is taken by mouth. It is a gamma-
amino-butyric acid (GABA) analogue that has an inhibitory action on spinal cord synapses.
Baclofen helps produce a “quieting” response message, that goes from the spinal cord to the
Because Baclofen crosses the blood brain barrier poorly, it is a good agent for delivery by the
more direct intrathecal route, where much lower doses are required and are associated with few
side effects. Intrathecal Baclofen administered by an implanted pump has been used in both
children and adults with spasticity. The technique requires the surgical implantation of a radio
frequency- controlled medication pump and the placement of a catheter in the subarachnoid
space. Direct intrathecal delivery of the medication reduces systemic side effects. This technique
allows the physician to address the drug dose for varying degrees of spasticity. When successful,
it allows for improved sleep, decreased pain, and enhanced mobility due to reduced spasticity.
X. Surgical Options
1. Tendon lengthenings, transfers, or releases
Tendon lengthenings reduce the tension on a muscle which decreases muscle tightness. The
procedure is done in a variety of ways. Sometimes the muscle is divided lengthwise into two
halves. The two ends are then re-adjoined to create a longer single tendon.
Sometimes, tendons can be moved from one position and attached to another with stitches in
order to balance the alignment of a joint. After tendon transfers, it is usually necessary to wear
solid casts, over the joint which is being addressed for approximately 3 to 6 weeks.
The tough covering around the muscle can also be cut. Tendons and muscles are left intact.
When the tough covering around the muscle is cut, greater range can be obtained. The muscle is
then casted in a lengthened position for approximately three weeks. This allows the covering to
scar down onto the muscle. One of the shortcomings of this procedure is that it may need to be
repeated in the future after a growth spurt.
In a myotomy, a muscle is actually cut and released. The muscle scars down onto a muscle near
In an osteotomy, a bone is actually cut and repositioned in a more functional position to correct
alignment. A metal plate and screws are inserted to hold the realigned bone into good position as
it heals. This requires a longer period of casting. Usually, six weeks in a non-removable cast and
six additional weeks in bivalve cast.
It takes the bone approximately 9 to 12 months to heal fully. Once the bone is healed, the metal
plate and screws can be removed, usually as an outpatient operation.
4. Posterior Rhizotomy
Posterior Rhizotomy is a neurosurgical technique that aims to reduce peripheral spasticity in the
lower limbs. It was first used experimentally in 1898 and was re-introduced for the pediatric
population in 1981. The theory is that increased muscle tone is secondary to overactivity of the
alpha motor neurons. Posterior rhizotomy reduces the spasticity by dividing some of the
posterior sensory rootlets from lumbar to sacral spinal nerves.
Selective rhizotomy divides only those rootlets associated with an abnormal electromyogram
(EMG) response to an intra-operative stimulation. The number of affected nerve roots varies
from 25% to 80%. Nonselective sectioning of the rootlets is performed without EMG monitoring
as well. The extent of surgery is determined by the degree of clinical spasticity. In both
techniques, the child requires anesthesia, a laminectomy, and a surgical procedure. The selective
technique takes longer due to the intra-operative EMG monitoring.
Children without contractures, deformities, or leg length discrepancies are better candidates. If a child might require multiple orthopedic interventions in order to address spasticity, then it may be more reasonable to consider posterior rhizotomy. Children with severe underlying hypotonia, scoliosis, hemiplegia, or extensive previous surgery are usually excluded from consideration. After surgery, extensive physical rehabilitation is required in order to strengthen muscles and teach the child new functional patterns. The risks and possible side effects of this technique include an unmasking of underlying hypotonia, transient hyperesthesia, and transient bowel and bladder impairment. Technique
Rhizotomy Pediatric Surgical
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