spasticity following near-drowning

[clarett]

Hi

I'm treating a 1 and a half year old boy who nearly drowned 2 months ago. He wasn't breathing for approx. 5 minutes. He is suffering from severe spasticity with very strong extensor spasms. We started positioning last week (on initial assessment) which has reduced his tone enough to make passive movements possible but it is still nearly impossible to flex his spine and he suffers from full extensor spasms every 3 or 4 seconds. I have tried trigger points but can't seem to find one that reduces the tone rather than triggering spasms.
He also cries all the time unless held by his mother.

He has not been able to track any objects with his eyes and it has been difficult to ascertain if he has any understanding of verbal commands. He sometimes responds to requests to turn his head or open his mouth but these responses are too inconsistent to know if they are voluntary.

Any suggestions would be gratefully appreciated. He has been recently seen by the neurologist and they are not going to make any further changes to his meds.

thanks

[ramywhite]

Hi clarett,
You didn't mention his chronological age. What he can do and what he can't do.
Can he raise his head from supine and/or prone? Can he control his back? What about his hand and upper extremity? We need more information?

[neurospast]

You will have more then a handfull of work to do. When I get this right; age 1.5 years, brain damaged due to nearly drowning, extreme extension spasm, no contact.
the first thing you should work on is contact because everything stands or falls with this. Otherwise you will never know which tactic does work. So it might be smart to work on sensoric imput (fysical contact!) like stroking massage etc. How does the child respond? Positive/ negative does it depend on where you touch? (most likely) Since it apperently has a strong extensor spasm you should try to avoid direct contact with the back, soles of the feet. But try it out because in that way you will learn. When you say positioning has brought the tone down. Which position are you talking about? I suppose more or less a sitting position, flexed hips and knees?
You have to realise that the damage has come at an age where the brains are still developing and so you have to consider the age of the child (1.5 years of age) as well as the set back due to the trauma. Look at the problem as it is cerebral palsy( at least it will give you some direction) and start from there, also how many hours a day are you treating the child? (I say delibrately hours a day, since I know you will not have the time) So you need to find some one you will train to do exercises with the child otherwise there is no point of having any input at all. Sinc ethe mother seems to have the best contact with the child the choice is obvious.
After my experience sound can have an extreme effect (like a firecracker exploding when you are unaware) I suppose the brain is in total chaos and small disturbances will provoke a massive respons (extension spasm!) But first of all Get contact!
Best of luck and realise it is worth it (not alike these stupid advertisements)

[saurabharora1974]

Originally Posted by clarett

Hi

I'm treating a 1 and a half year old boy who nearly drowned 2 months ago. He wasn't breathing for approx. 5 minutes. He is suffering from severe spasticity with very strong extensor spasms. We started positioning last week (on initial assessment) which has reduced his tone enough to make passive movements possible but it is still nearly impossible to flex his spine and he suffers from full extensor spasms every 3 or 4 seconds. I have tried trigger points but can't seem to find one that reduces the tone rather than triggering spasms.
He also cries all the time unless held by his mother.

He has not been able to track any objects with his eyes and it has been difficult to ascertain if he has any understanding of verbal commands. He sometimes responds to requests to turn his head or open his mouth but these responses are too inconsistent to know if they are voluntary.

Any suggestions would be gratefully appreciated. He has been recently seen by the neurologist and they are not going to make any further changes to his meds.

thanks

hi this is dr saurabh arora, i am working in India from last 9 years and have been into, nervous system disorders primarily, to me the case we have discussed seems to be absolutely a very good example of asphyxia, the patient of yours had suffered a considerable hypoxia and due to that the brain had suffered a considerable amount of damage caused due to lack of oxygen , as per experiments you must be knowing any thing above 3 minutes can damage the brain permanently and you ve said that he did not breathed till 5 minutes, any ways so far as the physiological condition is concerned we know what it is and why it is. but now the point of physiotherapeutic treatment comes up,
1, see that the spasticity you are facing dereases or not when the patient is sleeping.
2, when there is excessive extensor spasm you can not make your patient do any thing as even having him in supine position is going to be tough, make him lie prone on a pile of pillows, keeping in mind that at any time you do not let the intra cranial pressure go too high so keep watching the redness of the face.
3, tell his mother to do the activities in the initial one weeks plan as by that time he will get assured that you will be doing the same things as the mother is doing with him.
4, make him stand on the tilt table for atleast 45 minutes on a daily basis .
5, administer good dosage of any kind of muscle relaxant with the consult of the paediatrician they are seeking upon.
6, besides positioning you need to reduce his tonic labrynth too so make him roll on the large mattress, min. 20 to 30 rounds, you will see considerable lessening, in the spasticity.
thanks keep writing
saurabharora1974@yahoo.com

[clarett]

Thanks for your replies

The only contact that doesn't trigger extensor spasms is when his mother strokes his cheeks.

I have taught her how to do passive exercises for the whole body and to talk to him throughout doing the exercises and to try and include him as much as possible. She is also going to do sensory stimulation/massage with him.

After a week of treatment we managed to get him to accept a prone position for 30 seconds using several pillows (when we started prone actually increased the spasm and he didn't relax at all into flexion) but it is still a work in progress...

I have also advised her on how to start standing when she can get sufficient DF in the feet (currently in PF++ (probable shortening of gastroc) with toe flexion esp. big toe).

As for some of the other questions:
- spasticity is present awake & asleep
- positioning is sitting/supine with hip and knee flexion
- he has no active movements as such

They live over 3 hours away so I won't be seeing him again until later in July. I'll keep you updated as to how he goes.

Thanks again.

[wheatstone]

Fresh or salt water drowning? This will definitely impact prognosis. There's hope for improvement at this time, now is crucial and poor handling will adversely affect outcome. Check for reflex patterns (is he decorticate, decerebrate, can the extensor spasm be overcome, eg with moving head, etc) Need a baseline to work from.
And teaching mum, caregivers, etc what not to do in terms of positioning, handling, etc. I hope you're working with a good OT!
Good luck!