Publication Date

2017-05-09

Availability

Open access

Embargo Period

2017-05-09

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PHD)

Department

Nursing (Nursing)

Date of Defense

2017-04-04

First Committee Member

Victoria B. Mitraini

Second Committee Member

Kristopher Arheart

Third Committee Member

Bruce S. Rubin

Fourth Committee Member

Mary Hooshmand

Abstract

Spasticity is present in 80% of children experiencing Cerebral Palsy (CP) and 50% of those having sustained a Traumatic Brain Injury (TBI) (Tilton, 2015; O'Shea, 2008). Growth impairment among children with motor disabilities secondary to a Central Nervous System (CNS) insult is common and interferes with mobility, functioning comfort, and Quality of Life (QOL) (Vles, 2011; Mallarkey, 2009; Krick, Murphy-Miller, Zeger, & Wright, 1996). Spasticity may range fro mild to severe involving any body part (Mallarkey, 2009). There are a broad range of treatment modalities for managing spasticity impacting the child, parent or caregiver, and a multidisciplinary healthcare team (Brashear & Lambeth, 2009; Duff & Morton, 2007). Historically, nutritional and hormonal abnormalities have been the key contributing factors for growth retardation in children exhibiting CP (Kuperminc & Stevenson, 2008; Thommessen, M. et al., 1991). Pediatric growth assessment is a standard of care for all children who seek medical care (Krick, Murphy-Miller, Zeger, & Wright, 1996). Monitoring growth parameters in children over time, while ensuring obtainment of expected standards set by the Centers for Disease Control (CDC) and the National Centers for Health Statistics, is imperative for managing deficiencies (Pryor & Thelander, 1967). Nutritional and non-nutritional treatment modalities are most effective for reducing the consequences of spasticity and growth impairment upon discovery of abnormalities (Kumperminc, et al., 2013). Clinical observations have concluded a probable association of heightened caloric expenditure in association with spasticity (Andrew & Sullivan, 2010; Hemingway, McGrogan & Freeman, 2001). Oral antispasmodic medications and physiotherapy are the first line of treatment when managing spasticity. The use of Intrathecal Baclofen (ITB) therapy is a safe and effective method for controlling generalized spasticity (Gilmartin, et al., 2000; Penn, 1992). The observed impact that ITB has on reducing spasticity has been demonstrated through numerous clinical trials; however, the association between the reduction of spasticity and subsequent growth lacks investigation (Awaad, et al., 2002; Shilt & Cabrera, 2005). Through the retrospective observation of growth measurements of height, weight, and Body Mass Index (BMI) over time, changes in growth of children receiving ITB was studied. The testing of the relation between spasticity management, growth, and ITB therapy through quantitative analysis was compromised due to lack of data. Case studies were additionally performed to observe the growth over time in six subjects who had the greatest documentation of growth measurements. Among the case studies, two males presented with normal growth compared to four females who had growth below that compared to their peers. All case studies demonstrated controlled spasticity with the implementation of ITB and reduced Ashworth spasticity scores. Despite the lack of data, a linear regression analysis was conducted for random slopes and intercepts based upon z-scores. The results demonstrated a non-significant increase in height and weight, and a significant decrease in BMI among the sample group. These findings warrant the conduction of as study design allowing for appropriate standards of measurements to be performed at specific times for children experiencing spasticity receiving ITB and those who are not receiving ITB. The literature review supports improvements in growth secondary to ITB administration for the reduction of spasticity and with the implementation of gastrostomy tube feedings (Henderson, et al., 2007). The implementation of standard of care for all children, specifically those with CNS disorders is crucial to the early identification of growth retardation (Pin, McCartney, Lewis & Waugh, 2011).

Keywords

spasticity; cerebral palsy; growth retardation; intrathecal baclofen; traumatic brain injury; children

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