Spasticity, dystonia and tone management: Case

Clinical case of a 6-year-old girl with spastic diplegic cerebral palsy at GMFCS II presenting with adductor and calf spasticity causing scissoring, tip-toe gait and difficult care, covering the goal-directed assessment with the Modified Tardieu Scale and the GMFCS, the first-line focal botulinum toxin type A with its non-interchangeable dosing and twelve-week interval, the selective dorsal rhizotomy option with the McLaughlin and Tedroff evidence, the intrathecal baclofen withdrawal emergency, the dystonia pathway to GPi deep brain stimulation, and the multidisciplinary prevention of contracture hip subluxation scoliosis and pain.

paediatric neurodisability long case4 min readVerification in progress

Prompt

A 6-year-old girl with spastic diplegic cerebral palsy at GMFCS II walks independently with limitations. Her adductor and calf spasticity have caused scissoring and a tip-toe gait, and over the past year her nappy changing has become increasingly difficult because of tight adductors. She has good selective motor control, no dominant dystonia, and surveillance hip radiographs are currently within normal limits. Her family are highly motivated and engaged with the rehabilitation team.

Summary and immediate impression

This child presents a classic tone-management decision in spastic diplegic cerebral palsy. The adductor and calf spasticity are limiting both function, with scissoring and a tip-toe gait, and care, with difficult nappy changing, so the tone is a legitimate treatment target under the goal-directed principle. Her GMFCS level of two, her good selective motor control and her minimal dystonia together point toward focal botulinum toxin type A as first-line therapy, with selective dorsal rhizotomy as a definitive option to discuss with the family using the randomised-trial evidence. [1]

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References8Show ledger

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