NumberRecommendation
Principles of care
Delivering care
1Children and young people with spasticity should have access to a network of care that uses agreed care pathways supported by effective communication and integrated team working.
2The network of care should provide access to a team of healthcare professionals experienced in the care of children and young people with spasticity. The network team should provide local expertise in paediatrics, nursing, physiotherapy and occupational therapy. Access to other expertise, including orthotics, orthopaedic surgery and/or neurosurgery and paediatric neurology, may be provided locally or regionally.
3If a child or young person receives treatment for spasticity from healthcare professionals outside the network team, this should be planned and undertaken in discussion with the network team to ensure integrated care and effective subsequent management.
Management programmes
4Following diagnosis, ensure that all children and young people with spasticity are referred without delay to an appropriate member of the network team.
5Offer a management programme that is:
  • developed and implemented in partnership with the child or young person and their parents or carers
  • individualised
  • goal focused.
6When formulating a management programme take into account its possible impact on the individual child or young person and their family.
7Carefully assess the impact of spasticity in children and young people with cognitive impairments:
  • be aware that the possible benefit of treatments may be more difficult to assess in a child or young person with limited communication
  • ensure that the child or young person has access to all appropriate services.
8Identify and agree with children and young people and their parents or carers assessments and goals that:
9Record the child or young person's individualised goals and share these goals with healthcare professionals in the network team and, where appropriate, other people involved in their care.
10Help children and young people and their parents or carers to be partners in developing and implementing the management programme by offering:
  • relevant, and age and developmentally appropriate, information and educational materials
  • regular opportunities for discussion and
  • advice on their developmental potential and how different treatment options may affect this.
Supporting the child or young person and their parents or carers
11Offer contact details of patient organisations that can provide support, befriending, counselling, information and advocacy.
12Ensure that children and young people have timely access to equipment necessary for their management programme (for example, postural management equipment such as sleeping, sitting or standing systems).
13The network team should have a central role in transition to prepare young people and their parents or carers for the young person's transfer to adult services.
Monitoring
14Monitor the child or young person's condition for:
  • the response to treatments
  • worsening of spasticity
  • developing secondary consequences of spasticity, for example pain or contractures
  • the need to change their individualised goals.
15The network of care should have a pathway for monitoring children and young people at increased risk of hip displacement.
16Recognise the following clinical findings as possible indicators of hip displacement (hip migration greater than 30%):
  • pain arising from the hip
  • clinically important leg length difference
  • deterioration in hip abduction or range of hip movement
  • increasing hip muscle tone
  • deterioration in sitting or standing
  • increasing difficulty with perineal care or hygiene.
17Offer a hip X-ray to assess for hip displacement:
  • if there are clinical concerns about possible hip displacement
  • at 24 months in children with bilateral cerebral palsy.
18Consider repeating the hip X-ray annually in children or young people who are at Gross Motor Function Classification System (GMFCS) level III, IV or V.
19Consider repeating the hip X-ray after 6 months in children and young people where the initial hip migration is greater than 30%, and then consider repeating the hip X-ray every 6 months after this if the hip migration is increasing by more than 10 percentage points per year.
Physical therapy (physiotherapy and/or occupational therapy)
General principles
20All children and young people with spasticity referred to the network team should be promptly assessed by a physiotherapist and, where necessary, an occupational therapist.
21Offer a physical therapy (physiotherapy and/or occupational therapy) programme tailored to the child or young person's individual needs and aimed at specific goals, such as:
  • enhancing skill development, function and ability to participate in everyday activities
  • preventing consequences such as pain or contractures.
22Give children and young people and their parents or carers verbal and written (or appropriate formats) information about the physical therapy interventions needed to achieve the intended goals. This information should emphasise the balance between possible benefits and difficulties (for example, time commitment or discomfort), to enable them to participate in choosing a suitable physical therapy programme.
23When formulating a physical therapy programme for children and young people take into account:
  • the views of the child or young person and their parents or carers
  • the likelihood of achieving the treatment goals
  • possible difficulties in implementing the programme
  • implications for the individual child or young person and their parents or carers, including the time and effort involved and potential individual barriers.
24When deciding who should deliver physical therapy, take into account:
  • whether the child or young person and their parents or carers are able to deliver the specific therapy
  • what training the child or young person or their parents or carers might need
  • the wishes of the child or young person and their parents or carers.
25Ensure that any equipment or techniques used in the physical therapy programme are safe and appropriate, in particular for children or young people with any of the following:
  • poorly controlled epilepsy
  • respiratory compromise
  • increased risk of pulmonary aspiration
  • increased risk of bone fracture due to osteoporosis (for example, those who are unable to walk, malnourished or taking anti-eplieptic therapy).
26Encourage children and young people and their parents or carers to incorporate physical therapy into daily activities (for example, standing at the sink while brushing teeth in order to stretch leg muscles).
Specific strategies
27Consider including in the physical therapy programme 24-hour postural management strategies to:
  • prevent or delay the development of contractures or skeletal deformities in children and young people at risk of developing these
  • enable the child or young person to take part in activities appropriate to their stage of development.
28When using 24-hour postural management strategies consider on an individual basis low-load active stretching or low-load passive stretching.
29Offer training to parents and carers involved in delivering postural management strategies.
30Consider task-focused active-use therapy such as constraint-induced movement therapy (temporary restraint of an unaffected arm to encourage use of the other arm) followed by bimanual therapy (unrestrained use of both arms) to enhance manual skills.
31When undertaking task-focused active-use therapy consider an intensive programme over a short time period (for example, 4–8 weeks).
32Consider muscle-strengthening therapy where the assessment indicates that muscle weakness is contributing to loss of function or postural difficulties.
33Direct muscle-strengthening therapy towards specific goals using progressive repetitive exercises performed against resistance.
34Following treatment with botulinum toxin type A, continuous pump-administered intrathecal baclofen, orthopaedic surgery or selective dorsal rhizotomy, provide an adapted physical therapy programme as an essential component of management.
35Ensure that children and young people and their parents or carers understand that an adapted physical therapy programme will be an essential component of management following treatment with botulinum toxin type A, continuous pump-administered intrathecal baclofen, orthopaedic surgery or selective dorsal rhizotomy.
Continuing assessment
36Reassess the physical therapy programme at regular intervals to ensure that:
  • the goals are being achieved
  • the programme remains appropriate to the child or young person's needs.

From: 4, Physical therapy (physiotherapy and/or occupational therapy)

Cover of Spasticity in Children and Young People with Non-Progressive Brain Disorders
Spasticity in Children and Young People with Non-Progressive Brain Disorders: Management of Spasticity and Co-Existing Motor Disorders and Their Early Musculoskeletal Complications.
NICE Clinical Guidelines, No. 145.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2012 Jul.
Copyright © 2012, National Collaborating Centre for Women's and Children's Health.

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