eMedicine Specialties > Physical Medicine and Rehabilitation > Medical Diseases
Cerebral Palsy: Treatment & Medication
Updated: Mar 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Treatment associated with cerebral palsy is aimed at improving infant-caregiver interaction, giving family support, supplying resources, and providing parental education, as well as at promoting motor and developmental skills. The parent or caregiver should be taught the exercises or activities that are necessary to help the child reach his or her full potential and improve function.6,7
Daily range-of-motion (ROM) exercises are important to prevent or delay contractures that are secondary to spasticity and to maintain the mobility of joints and soft tissues. Stretching exercises are performed to increase motion. Progressive resistance exercises should be taught in order to increase strength. The use of age-appropriate play and of adaptive toys and games based on the desired exercises are important to elicit the child's full cooperation. Strengthening knee extensor muscles helps to improve crouching and stride length. Postural and motor control training is important and should follow the developmental sequence of normal children (that is, head and neck control should be achieved, if possible, before advancing to trunk control).
The child's developmental age should always be kept in mind, and adaptive equipment should be used as needed to help the child achieve his or her milestones. For example, if a child is developmentally ready to stand and explore the environment but is limited by a lack of motor control, the use of a stander should be encouraged to facilitate the achievement of the youngster's milestones. Performance should be encouraged at a level of success to maintain the child's interest and cooperation, and assistive devices and durable medical equipment should be ordered to attain function that may not otherwise be possible.
Orthoses are frequently required to maintain functional joint position in the upper and lower extremities, especially in nonambulatory or hemiplegic patients. Frequent reevaluation of orthotic devices is important because children quickly outgrow them and can undergo skin breakdown from improper use of this equipment.
Splints should be worn as much as possible without causing skin breakdown (at least 6 hours to provide a good stretch or sometimes a schedule of 2 hours on, 1 hour off throughout the day). Orthoses can become especially important in ambulatory cerebral palsy to improve gait, decrease contracture, and increase endurance. Patients with cerebral palsy have a very inefficient gait pattern, and there can be an energy expenditure gain of as much as 350%. Orthoses can be of great benefit, and while wearing them, patients can potentially suffer fewer trips and falls.
Patients and their parents often like hippotherapy (horseback-riding therapy) to help improve the child's tone, ROM, strength, coordination, and balance. Hippotherapy offers many potential cognitive, physical, and emotional benefits.
The use of Kinesio Taping can help in reeducating muscles for stretching and strengthening. Aquatic therapy also can be beneficial for strengthening, as can electrical stimulation.
Occupational Therapy
Occupational therapy for children with cerebral palsy should focus on activities of daily living, such as feeding, dressing, toileting, and grooming. The goal should be for the child to function as independently as possible with or without the use of adaptive equipment. (See also Physical Therapy.)
Speech Therapy
Many children with dyskinetic cerebral palsy and some with spastic cerebral palsy have involvement of the face and oropharynx, causing dysphagia, drooling, and dysarthria. Speech therapy can be implemented to help improve swallowing and communication. Some children benefit from augmentative communication devices if they have some motor control and adequate cognitive skills. Patients with athetoid cerebral palsy may benefit the most from speech therapy, because most of these individuals have normal intelligence, and communication is an obstacle that is secondary to the effect of athetosis on speech. Adequate communication is probably the most important goal for enhancing function in a patient with athetoid cerebral palsy. Many children with cerebral palsy have feeding difficulties that also would benefit from speech therapy.
Related eMedicine topics:
Communication Disorders
Drooling
Dysphagia
Swallowing Disorders
Recreational Therapy
Incorporation of play into all of a child's therapies is important. The child with cerebral palsy should view physical and occupational therapy as fun, not work. Caregivers should seek fun and creative ways to stimulate children, especially those who have a decreased ability to explore their own environment.
Medical Issues/Complications
- Spasticity and/or contractures
- Pulmonary complications - Including aspiration, oromotor dysfunction, bronchopulmonary dysplasia (seen in premature infants)
- Dental problems - Including enamel dysgenesis, malocclusion, caries, gingival hyperplasia (Malocclusion is twice as prevalent as in the normal population.) An increased incidence of dental problems is often secondary to the use of medications, especially drugs administered to premature infants and antiepileptic agents.
- GI symptoms (eg, reflux, constipation) and/or dysphagia - May cause failure to thrive, resulting in growth failure; patients may require a gastrostomy tube (G-tube) or a jejunostomy tube (J-tube) to augment nutrition. Nutrition consultation should be done early and periodically to ensure proper growth. Parents and medical professionals must keep on top of the potential nutritional difficulties in children with cerebral palsy. These patients are especially at risk of developing osteoporosis because of decreased weight bearing, so following their calcium intake is important.8
- Mental retardation - Seen in 30-50% of children with cerebral palsy, most commonly associated with spastic quadriplegia
- Hearing loss - Especially in children with hyperbilirubinemia; also seen in patients who were born prematurely or who were exposed to ototoxic drugs
- Spasticity - Causes stress on the joints, leading to misalignment, especially in the hips and spine
- Scoliosis and kyphosis
- Dislocated hips
- Pain
- Neglect - More prevalent than in the normal population
- Failure to thrive/malnutrition
- Osteoporosis
- Social isolation
- Sialorrhea - excessive drooling; can cause associated skin problems, as well as social isolation
Surgical Intervention
- Scoliosis and hip dislocation - The most common conditions requiring surgery.
- Scoliosis repair
- Hip relocation surgery for dislocations
- Tendon lengthening or transfer - To decrease spastic muscle imbalance and deforming forces
- Osteotomy to realign limb - Including the femoral neck, tibia, and calcaneus
- Intrathecal insertion of a baclofen pump to treat spasticity and/or dystonia - Useful in the patient with diffuse spasticity or dystonia; the baclofen pump is most useful in helping to decrease spasticity in the lower extremities and trunk, but it can also reduce spasticity in the upper extremities and improve speech. The degree of improvement in the upper extremities is increased with higher placement of the pump catheter. The dose can be adjusted by the physician with an external handheld programmer, with different doses administered during the day and evening, depending on the patient's needs. Surgery is required for placement of the pump, and the patient will need monthly appointments to refill the pump with intrathecal baclofen. The monthly refills are performed in the physician's office, with a single percutaneous needlestick used to access the pump's refill port.
- Selective posterior rhizotomy to treat velocity-dependent spasticity - Includes a laminectomy and then surgical ablation of 70-90% of the dorsal or sensory nerve roots
- Gait analysis has revealed improved ROM at the knee and hip, with improved stride length.
- Patients must be selected carefully because the weakness produced may decrease the level of functional independence. Underlying weakness is uncovered with the decrease in spasticity. Some patients also depend on some of their spasticity to stand or walk.
- This surgery has come to be performed less frequently since the advent of the baclofen pump.
- Because of the laminectomies, some of the earlier surgeries had complications of more severe lumbar lordosis several years after surgery. Most surgeons are currently doing smaller laminectomies of only 1-2 levels.
Consultations
- Regular visits with a rehabilitation specialist are important to help coordinate the care of these often very involved patients. A rehabilitation specialist can also help with many aspects of care, including, but not limited to, those relating to spasticity management, therapies, modalities, bracing, sialorrhea, and insomnia.
- A neurologist may help with differential diagnosis and with ruling out other neurologic disorders. Consultation with a neurologist may also be helpful in the treatment of patients with seizures.
- A specialist in genetics may help with the differential diagnosis and with ruling out other disorders.
- An orthopedic surgeon may be needed to help correct any structural deformities.
- Consultation with an ophthalmologist may be indicated for follow-up of any patient experiencing visual deficits.
- An audiologist may help to screen for hearing deficits.
- A pulmonologist may help to treat the patient who has bronchopulmonary dysplasia or frequent aspiration pneumonia.
- A gastroenterologist may help with reflux and constipation and may aid in coordinating feedings to regulate weight gain or loss, if needed. A G-tube or J-tube also may be needed to help augment nutrition. A periodic nutrition consultation is important to make sure that the child does not suffer from growth failure or nutritional deficiencies.
- Regular dental visits are important.
- And endocrinologist is occasionally needed for precocious puberty or treatment of osteoporosis.
Other Treatment
- Orthotic devices may help children with cerebral palsy to control limb position during gait; also, if appropriate seating is needed, a wheelchair and mobility aids may help.
- A manual wheelchair may be needed, with seating adaptations included to keep the back straight and protect the hips from excessive adduction or abduction. The early introduction of independent mobility is important because the ability to explore one's environment has been demonstrated to improve self-esteem.
- A power wheelchair may be needed for children with severe spasticity or athetosis. A power wheelchair can be introduced to children aged 3 years who have normal intelligence. However, a child needs to understand the concept of cause and effect to use the device appropriately.
- Orthotic devices such as an ankle-foot orthosis help to maintain foot position and prevent worsening contractures.
- Walkers also may be prescribed to enhance mobility. Any child with the ability and/or desire to ambulate should be given every opportunity to do so. A posterior walker promotes a more upright posture than do traditional walkers.
- Phenol intramuscular neurolysis and botulinum toxin intramuscular blocks reduce spasticity for 3-6 months.9,10,11,12
- The established total body dose of botulinum toxin is limited to 12 U/kg, to a maximum of 400 U per visit. (Many practices, however, have been safely using 20 U/kg, to a maximum of 600 U). Each small muscle receives 1-2 U/kg, and large muscles, 4-6 U/kg. The interval between doses should be at least 4 months in order to help prevent antibody formation, which could make subsequent botulinum toxin procedures less effective.
- Large muscles may not respond to this limiting dose, or quite often, patients need several muscles done at each visit.
- Phenol can be used for some large muscles or when several muscles are treated, but this therapy is more difficult to administer than are others. Because it is administered using a nerve stimulator, phenol treatment is more painful, and anesthesia is often used when the therapy is performed. Because phenol can, in certain nerves, cause unpleasant sensory dysesthesias, its use is often limited to nerves with only motor innervation, such as the musculocutaneous (for decreasing arm flexion) and the obturator (for decreasing hip adduction). It is also used for hamstring motor point blocks (for knee flexion).
- Short-term use of heat and cold over the tendon may help to decrease spasticity; vibration over the tendon also reduces spasticity. However, these treatments only decrease spasticity briefly and should be used in conjunction with ROM and stretching exercises.
- Casting and splinting can improve the ROM of a joint and decrease tone. This is particularly completed at the ankles to help with plantar flexion contractures, but it also can be done on any contracted joint to provide a slow, progressive stretch.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Skeletal Muscle Relaxants
These are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.
Baclofen (Lioresal)
GABA analog that inhibits calcium influx into presynaptic terminals and suppresses the release of excitatory neurotransmitters. Baclofen undergoes rapid GI absorption, which peaks in 1-2 h. It is primarily excreted renally and is partially metabolized by the liver. Baclofen works better in the treatment of spinal spasticity than it does against cerebral spasticity, but the drug should be tried against both conditions. The drug's use is often limited by CNS adverse effects, and thus, an effective dose is usually not obtainable with oral dosing. Intrathecal baclofen is available for use with a surgically implanted pump, which may improve the effectiveness of doses.
Adult
5-10 mg PO tid initially; increase 5 mg/dose q3d; not to exceed 80 mg/d
Pediatric
Begin with 10-15 mg/d PO divided q8h; increase 5 mg/d q3d; not to exceed 60 mg/d
Co-administration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Dantrolene (Dantrium)
Inhibits the release of calcium into the sarcoplasmic reticulum. Dantrolene may weaken even nonspastic muscles. It is generally used only in patients with severe hypertonicity.
Adult
25 mg/d PO; increase tid/qid, then increase dose by 25 mg q4-7d; not to exceed 100 mg bid/qid or 400 mg/d
Pediatric
0.5 mg/kg PO; increase tid/qid at 4-7 d intervals, then increase dose by 0.5 mg/kg; not to exceed 3 mg/kg/dose bid/qid or 400 mg/d
Toxicity may increase with the co-administration of clofibrate and warfarin; co-administration with estrogen may increase hepatotoxicity in women older than 35 years
Documented hypersensitivity; active hepatic disease (hepatitis and cirrhosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause hepatotoxicity (use only for recommended indications); caution in impaired pulmonary function and severe cardiac insufficiency; may cause photosensitivity with exposure to sunlight
Benzodiazepines
These agents may act in the spinal cord to induce muscle relaxation.
Diazepam (Valium, Diazemuls)
Presynaptic GABA agent that results in increased presynaptic inhibition at the spinal and supraspinal sites. Diazepam undergoes rapid GI absorption; renal excretion and hepatic metabolism occur.
Sedation is common. Diazepam may worsen swallowing problems. The drug is generally used only in patients in whom severe hypertonicity is compromising care.
Adult
2-10 mg PO bid/qid
Pediatric
0.12-0.8 mg/kg/d PO divided q8 h
Increases toxicity of benzodiazepines in CNS with co-administration of phenothiazines, barbiturates, alcohols, and MAO inhibitors
Documented hypersensitivity; comatose patients or patients with pre-existing CNS depression, respiratory depression, narrow-angle glaucoma, or severe, uncontrolled pain
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Neuromuscular Blocker Agent, Toxin
These agents paralyze the muscle by blocking neurotransmitter release.9,10,11,12
Botulinum Toxin Type A (Botox)
Blocks acetylcholine release at the neuromuscular junction by cleaving the SNAP-25 protein located on the plasma membrane. This causes weakness in the muscle into which botulinum toxin type A (abbreviated BoNT-A) is injected.
Adult
400 U into affected muscle
Pediatric
12 U/kg total body dose up to 400 U max
(although many practices have used 20 U/kg, to a max of 600 U total body dose); each small muscle receives 1-2 U/kg, and large muscles receive 4-6 U/kg
There are established recommended doses for each muscle available at the botulinum toxin manufacturer's website
Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects of botulinum toxin
Documented hypersensitivity; infection present at injection site
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not exceed recommended dosages and frequencies of administration; presence of antibodies to BoNT-A may reduce effects of therapy; when used for cervical dystonia, may cause dysphagia, upper respiratory infection, neck pain, or headache; blepharoptosis may occur when the drug is used for blepharism or strabismus; weakness of hand muscles and blepharoptosis may occur when used for palmar or facial hyperhidrosis, respectively
When used cosmetically for glabellar lines, may cause headache, respiratory infection, flu syndrome, blepharoptosis, or nausea
Alpha2 Adrenergic Agonist Agent
Tizanidine is an imidazoline derivative and a central alpha2 noradrenergic agonist. The antispasticity effects are the probable result H-reflex inhibition. The drug may facilitate the inhibitory actions of glycine, reduce the release of excitatory amino acids and substance P, and produce analgesic effects.
Tizanidine (Zanaflex)
Centrally acting muscle relaxant metabolized in the liver and excreted in urine and feces.
Adult
4-8 mg PO q8h prn; not to exceed 36 mg/d
Pediatric
Not established
May interact with alcohol (causing increased somnolence, stupor) and oral contraceptives (which decrease its clearance), and can cause increased hypotensive effects when administered concurrently with diuretics; serum concentration and resulting toxicity (ie, hypotension, sedation) increased when co-administered with CYP1A2 inhibitors (eg, fluvoxamine, zileuton [Zyflo], fluoroquinolones [ciprofloxacin, levofloxacin], anti-arrhythmic agents [amiodarone], cimetidine [Tagamet], famotidine [Pepcid], oral contraceptives, acyclovir [Zovirax], ticlopidine [Ticlid])
Documented hypersensitivity; co-administration with potent CYP1A2 inhibitors (ie, fluvoxamine [Luvox], ciprofloxacin)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
More on Cerebral Palsy |
| Overview: Cerebral Palsy |
| Differential Diagnoses & Workup: Cerebral Palsy |
 Treatment & Medication: Cerebral Palsy |
| Follow-up: Cerebral Palsy |
| Multimedia: Cerebral Palsy |
| References |
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References
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Further Reading
Keywords
cerebral palsy, palsy, spastic, spasticity, hemiplegia, quadriplegia, diplegia, palsy treatment, children with cerebral palsy, cerebral palsy symptoms, cerebral palsy treatment, spastic diplegia, spastic cerebral palsy, ataxic cerebral palsy, spastic quadriplegia, spastic monoplegia, cerebral palsy causes, monoplegia, encephalopathy, spastic palsy, dyskinetic palsy, ataxic palsy
