Therapeutics, Pharmacology and Clinical Toxicology

Vol XV, Number 2, June 2011 THERAPEUTICAL PRACTICE

Pages 144-150
© Copyright reserved 2011

CEREBRAL PALSY MANAGEMENT

Ioana Minciu

Prof. Dr. Alexandru Obregia Hospital, UMF “Carol Davila”, Bucharest

Abstract. At this moment there are no treatment guidelines for cerebral palsy, and also no treatment
for the brain lesion that leads to characteristic motor dysfunctions. Therefore the therapeutic interven-
tion is only symptomatic, targeting the motor and associate disturbances equally (co morbidities). This
paper reviews the existent therapeutic options, based on the literature data. Functional therapy, orthosis,
injecting botulium toxin, occupational therapy, intrathecal Baclofen, surgical treatment, are available as
options at the moment. Unfortunately, there are not enough studies to prove the superiority of a treat-
ment over another.
Keywords: cerebral palsy, physiotherapy, oral medications, botulinum toxin

Introduction bone deformities, by decreasing or even normal-

C erebral palsy represents a group of non-

progressive, persistent disturbances of
movement and posture, with early onset, due to
izing muscle tone, and increasing joint mobility;
b) increasing muscular strength on weak muscles;
c) improvement of mobility and gaining motor
non-progressive disease, appearing on an immature functional skills.[2]
or developing brain (pre-natal, peri-natal, post-natal From the moment we are communicating the
in the first 3-4 years of life).[1] It is associated with: diagnosis to the parents (and this is done only
cognitive, sensitive or/and behavioral impairments when it is certain) we must be aware about the
and epilepsy. At this moment there is no cure for implications that this has on the family and society.
cerebral palsy associated with characteristic motor It is preferable to communicate to the parents only
or coordination dysfunctions. Therapeutic interven- short term prognosis and to propose realistic thera-
tion targets only the symptoms, motor and associ- peutic objectives. The family must become a stable
ated impairments (co-morbidities). structure to support the purpose of the treatment
Cerebral palsy is a life lasting disability and is “the child must become what he/she can become
one of the most expensive diseases. Final goal of according to the circumstances”. [3] Along with the
the treatment is to obtain the maximum functional family, diferent medical specialitists are involved
potential (ideal), or (more realistic) to insure in- in cerebral palsy treatment: general practitioner,
dependence in daily home, school or community pediatrician, neurologist, orthopedist, psychiatrist,
routine activities for the patients, and the best and educational system and community, as well.
quality of life possible. There are no treatment guidelines for this dis-
The objectives of the treatment are: a) decreasing ease, still there are mainly two types of treatment
to the minimum of the muscular contractions and options: conservative and invasive.
1. Conservative treatment consists in func-
tional therapy or physiotherapy which is the main
Ioana Minciu therapeutic intervention for the motor and tonus
Prof. Dr. Alexandru Obregia Hospital disorders, occupational therapy, speech therapy and
10 Şos. Berceni, Sector 4, Bucharest treatment of swallowing disorders, placing orthosis,
e-mail: iminciu@yahoo.com which is associated with oral drug treatment for

144 Therapeutics, Pharmacology and Clinical Toxicology

Ioana Minciu

spasticity, dystonia and other associated disorders

(epilepsy, sleep disorders, hyperkinesias, behavioral
disorders, gastro-intestinal disorders, pain).
1.1 Functional therapies are addressing all
cerebral palsies. It is applied by the physiotherapy
specialist and it is differentiated by age.
In infants it seems important to start physi-
cal therapy as soon as possible, but there are not
enough studies to show the benefits of early inter-
vention.[4,5] In this stage the therapy is focused on
stimulating motor development and normalizing
muscular tone.
During the motor learning period, until 5 years
of age, the therapy has the most impact, and the
cerebral palsy diagnosis is certain. The therapy is
focused on gaining major motor skills: sitting and
Figure 1. Bobath therapy - passive exercise in the ankle
standing positions, walking, running, jumping,
and knee joint (Source: Personal archive)
climbing the stairs, and so on, but it also focuses
on maintaining joint mobility and preventing mus-
cular contracture and joint deformity. Occupational
therapy, focused on gaining elementary habits of
self-serving: eating, putting on and taking off the
clothes, washing, etc, speech therapy and treating
swallowing disorders, it is useful at this age, as well.
For the 6-10 years old children with low cogni-
tive level, the same therapy focused on motor skills
is maintained, but for those with a good cognitive
level, motor therapy will go on improving motor
skills and learning to use helping devices (crouches,
wheelchairs), but the main focus will be on school-
ing and accessing the educational system.
For puberty and adolescence, the focus is again
on educational system, the therapy remaining pure
motor only for those with low cognitive abilities
(even if it is very rare, these children may begin
walking after 12 years). For those with good cogni- Figure 2. Bobath therapy - passive movement in the ankle
tive level, the maintaining physical therapy has very joint (Source: Personal archive)
precise purposes, patient being directly involved and
responsible in the physical activities and encouraged
towards sports.
In adulthood, the role of physical therapy is
reduced to some specific functional goals. Those
with good cognitive level will perform physical and
stretching exercises alone. For those with a low
cognitive level, the caregiver will be instructed for
the physical and stretching exercises.

Major treatment protocols

Neuro-developmental approach – Bobath
therapy, (developed by Bobath husbands in England
in 1940). It is based on���������������������������
: a.) correcting the abnor-
mal tonus by using passive exercises, encouraging
normal motor models and positioning (fig 1,2,3,4);
b).erasing primitive abnormal reflexes by repeated
stimulation, c) working on automatic reactions (i.e. Figure 3. Bobath therapy - alternant movements (Source:
parachute reaction), so the child will be guided Personal archive)
towards normal movement patterns, avoiding ab-
XV, Vol.15, Number 2/2011 145
 Cerebral palsy

Figure 4. Bobath therapy - passive movements in the arms Figure 6. Vojta therapy - phase 2 of reflex rolling, stimula-
(Source: Personal archive) tion from lateral position (with pressure points on the up-
per shoulder and on the knee below, it ends up in a ventral
position) (Source: Personal archive)

Figure 5. Vojta therapy-phase 1 of reflex rolling, stimula-

tion from supine ( by stimulation in the intercostal space it
ends up with turning on the side) (Source: Personal archive) Figure 7. Vojta therapy - it shows presure points used for
stimulation - reflex crawling, stimulation from ventral posi-
tion ( it combines pressure under tibial external malleolus
normal postures. It should be applied as soon as
and shoulder) (Source: Personal archive)
possible. There are not enough studies to certify
the benefit or the superiority to other interventions.
There is little evidence regarding the efficacy on answers with certain purpose/usefulness. The goal
neuromotor development. [6] is that the sensory input followed by adequate mo-
Sensory-motor therapy - Rood therapy (devel- tor answer will lead to the development of higher
oped in 1950 in USA by Margaret Rood). It is based cortical motor sensory functions. Typical stimula-
on tactile stimulations to facilitate movement with tion includes visual, vestibular, proprioceptive and
the purpose of activating autonomic movement, as tactile stimulation. There are no objective proofs
it happens with normal postural answers. It is based of its efficacy.
on 8 sequences of movements: supine withdrawal, Vojta Therapy (developed between 1950-1960
rolling over, pivot prone, neck co-contraction, elbow by dr Vojta) it is used for infants. It is widely used
weight bearing, all four limbs weight bearing, stand- in Europe and Japan. It uses proprioceptive trigger
ing, and walking. There are no objective reports on points from the body and limbs to initiate reflex
the efficiency of this method. movements that lead to rolling, crawling, etc. It is
Sensory integration therapy – Ayers technique done on daily basis by family. [7] (fig 5,6,7)
(developed in 1970 by AJ Ayers) is based on the Patterning therapy Doman-Delacato (developed
integration of sensory feedback to produce motor in 1960-1970, very used in the past in Philadelphia
146 Therapeutics, Pharmacology and Clinical Toxicology
Ioana Minciu

region) – is based on the recapitulation theory (dur- Manual or external devices passive stretching
ing the development, immature activities rehearsal techniques – not even in this case are enough data
will stimulate to develop higher activities). It needs to sustain the efficacy of this treatment.[10]
many hours of daily work, and it was almost aban- Alternative therapies: acupuncture, massage
doned because it did not prove other benefits than and mio-fascial relaxation, reflexology, hyperbaric
keeping joint mobility. [8] oxygen therapy, hydrotherapy.
Peto technique – conductive education (devel- Studies on alternative therapies, have shown no
oped in the 1940-50 by Andrea Peto in Hungary), difference in the regards of disability, are costly, time
for patients that have some useful motor functions, consuming and potentially risky by some authors.[9]
but are not independent, and is stimulating the gain Physical therapy is always associated with
of some behaviors that they can perform either other treatment programs: treatment of swallow-
very bad or partially and will be helped until they ing, speech, mastication, and occupational therapy.
acquire this behavior. There are used simple devices 1.2 Splinters and devices to bear the weight,
for help (for example a simple ladder) [7, 9 ] to maintain the position and walk, orthosis can
Electrical stimulation therapy has as its purpose be used in association with physical therapy – there
the hypertrophy of muscles and the increase of is no evidence on the long term benefits regarding
muscular strength. It is done usually during the their use.
night, but is possible also during the day with in- They are used early in the therapeutic plan
tensity reduced below the level the child can feel and help preventing or correcting bone and joint
and does not produce muscular contractions. It is deformities, bearing and stabilization of the body
based on the increase of the local blood flow. There in some postures to help moving and permit some
is not enough data regarding its indications and activities that otherwise would be limited. Static
benefits. Because it is painful, electric stimulation orthosis are sustaining the joints, help stretching
could be applied only rarely to adolescents and spastic muscles, maintain joint mobility and prevent
adults. (figure 8) deformity. Dynamic orthosis line up the segments
in the joint, stimulate and help normal movement,
blocking vicious movements. Their usage depends
on patient compliancy.
Using splinters in combination with injecting
botulinum toxin has shown in some studies a higher
efficacy to splinters alone, or injections without
splinters. [11, 12]
1.3 Occupational therapy is the mirror of the
physical therapy and they overlap from the beginning
of physical therapy. While the child is gaining motor
functions, occupational therapy is oriented towards
daily routine activities and fine motor abilities with
upper limbs, improving coordination in space. At a
small age the activities followed are for self serving:
eating, clothing, drawing, using scissors; at middle
ages: putting the shoes, clothing, washing, writing. If
Figure 8. Electrostimulation on the anterior tibial muscle the motor disturbance is high and prevents writing,
(Source: Personal archive) the child with good cognitive level will be helped at
writing with dictaphone and computer. For teenagers
the main goal is to achieve personal autonomy, and
Increasing the muscular tone and strength the therapy will have a precise purpose (i.e. putting
therapy is used for hypotonic muscles or for the the shoes). For adults, as for teenagers, treatment will
antagonists of spastic muscles. have in sight specific objectives (i.e. driving a car).
Constraint induced therapy is useful for the up- Medical treatment of spasticity will take into ac-
per limb in hemiplegic patients: - the uninvolved count the decrease of muscular tone at the moment
arm is periodically immobilized in a cast to improve and the place were it disturbs the performances.
the use of paralyzed arm. There is no data regard- We will bear in mind that some spastic muscles
ing the age for beginning, the level of disabilities, are helping the patient to maintain the weight in
duration of the treatment, and also regarding the orthostatic position and walking, and that lowering
long term benefits. the tonus of these muscles will lead to the incapac-
Balance techniques for patients with balance ity of the patient to walk.
disturbances/horse ridding therapy

XV, Vol.15, Number 2/2011 147

 Cerebral palsy

1.4 Oral medication the fatigue, increasing effort capacity in patients

Oral anti-spastic medication is generally used with prematurity spastic dyplegia. Modafinil has
rare and limited in time due to side effects and only shown good effects on spastic hemi and tetra pa-
for patients with severe functional impairment (III, resis group as well, by decreasing muscular tone,
IV, V degree Gross Motor Function Classification increasing mobility and reducing pain. [16].
System- GMFCS). [13, 14] (table I). Its purpose Other oral drugs:
is to decrease the tonus and pain, to facilitate the Anti-spastic effects were observed with voltage-
physical care, positioning and to solve some acute dependent sodium channels blocking medication
situations (agitation, sleep disorders, seizures). (Lamotrigine and Riluzole), serotonin agonists

The
Active
pharmacologic Advantages Disadvantages Dosage
substance
effect
Adult: 5-10 mg x3/day, increase by 5
mg/dose at 3 days - max 80 mg/day
GABA inhibitor Intratecal Rapid installation
Children:10-15 mg/day -3 doses,
Baclofen receptors administra- of tolerance,
increase by 5 mg/dose at 3 days - max
tion sedative effects
30-40mg/day under 7 years and 60
mg/day over 7 years
Adult: 2-10 mg 2-4x/day
GABA inhibitor Rapid installation
Diazepam postsurgery Children: 0,12-0,8 mg/kg/day in 3
receptors of tolerance
doses.
Sleep Sedative effects,
GABA inhibitor
Clonazepam disorders, rapid installation 0,01mg-0,1 mg/kg/day
receptors
antispastic of tolerance
Agonist of α2
Antispatic and Insufficient data Adult: 4-8 mg/ 8 hours maximum 36
Tizanidine adrenergic
analgezic in children mg/day
receptors
Adult: 25 mg /dose lent increase to
Decrease maximum 400 mg/day oral route
Decrease the
calcium release Children: 0,5 mg/kg /dose lent
Dantrolene extension of hepatotoxic
in sarcoplasmic increase to maximum 3 mg/kg/dose
muscular fiber
reticulum 2-4 times/day or maximum 400mg/
day
Dependence
Canabis psihotrop antispatic Insufficient data No data
in children
Antispastic,
Modafinil CNS Stimulant 3 mg/day
analgezic

Tabel I. Description of oral anti-spastic drugs

One of the newer GABA receptor inhibitor (ciproheptadin). Regarding ciclobenzapine, studies
drugs, tetrazepam and ketazolam, have fewer side have shown low effects on spasticity.
effects and are used more frequently in adults. For difficult to treat chorea and athetosys, were
Some α2 adrenergic receptors agonists, tizani- tried benzodiazepines, neuroleptics (ex. haloperi-
dine and clonidine hydrochloride inhibit the me- dol), anti-parkinsonian (ex. levodopa), anti-cholin-
dullar spasticity by blocking H reflex. Tizanidine ergic drugs. Anti-cholinergic drugs are useful in
facilitates the inhibiting actions of glycine, reducing reducing rigidity, akinesia, tremor and over-drooling
the release of excitatory aminoacides and P sub- (trihexifenidil initial dose of 1-2 mg/day in adults,
stance and has analgesic effects.[15] increased with 2 mg/day at 3-5 days up to 4-15
Recent studies have shown benefits in cerebral mg/day divided in 3-4 intakes.)[15].
palsy treatment with Modafinil, a CNS stimulant, 2. Invasive procedures
which has decreasing effect on spasticity and good 2.1 Intrathecal administrated medication
effect on achieving or improving walking, reducing For first time Baclofen was administrated intra-
148 Therapeutics, Pharmacology and Clinical Toxicology
Ioana Minciu

thecal in 1984, and FDA approved it for spasticity muscle into which botulinum toxin type A (ab-
in cerebral palsy treatment in 1992 for adults and breviated BoNT-A) is injected. Therapeutic effects
only in 1997 for children. It’s a reversible proce- may last 3-6 months. You can repeat the injection
dure. It is used for patients with severe dysfunction: but not earlier than 4 months to prevent antibody
(III) IV-V degree GMFCS [2, 3] with spasticity or development. (fig 9.)
dystonia of cerebral or spinal cause, generalized, It is used in association with physiotherapy and
significantly interfering with movement, positioning, orthosis, and it is useful in localized spasticity (2-4
or which give pain and joint deformity. It consists muscles at most), or in dystonia. Commercial names
from a programmable pump, surgically placed under for the botulinum toxin are Dysport or Botox.[17] .
the abdominal skin or under the external oblique For I-III GMFCS level of spasticity, the main scope
aponeurosis with a reservoir attached to a catheter is to reduce muscular hypertonia and the imbalance
going to the subarachnoid space of spinal channel of flexing-extending muscles, allowing the passive
at lumbar or thoracic level (usually T6-7). Useful adjustment of the joints’ limbs, elongation of spastic
dose is 100-200 μg/day. muscles, better tolerance at wearing orthosis and
Baclofen is acting through diffusion at superfi- preventing or delaying the induction of abnormal
cial layers of gray matter of the spine were GABA muscle contracture. For IV-V GMFCS level, the
receptors are located. The strengths in CSF is 10 main scope is not functional improvement, but to
times larger then after oral administration. Side ef- facilitate the care giving, reducing pain, wearing the
fects: respiratory distress, infection at the catheter orthosis, controling the drooling. Adverse events
or pump site, mechanical problems of the catheter associated with botulinum toxin use are: asthenia,
or pump. generalized muscle weakness, diplopia, blurred
2.2 Injury of motor peripheral nerves by vision, ptosis, dysphagia, dysphonia, dysarthria,
chemical disconnection urinary incontinence, and breathing difficulties.
Local injection of alcohol or phenol was mostly 2.4 Alcohol and phenol injections in the
used in the 70’s, today are almost abandoned be- muscles was abandoned nowadays, as it’s already
cause there are toxic, very painful (they are done , mentioned, and more over, large quantity of this
with general anesthesia), the effect of decreasing substances are producing muscular fibrosis.
the spasticity persist for 1-3 month for alcohol and The recommendations of American Academy of
18-24 month for phenol. Neurology and Pediatric Neurology Society, regard-
2.3 Local injections in the muscles with botu- ing the spasticity treatment in cerebral palsy (a new
linum toxin is one of the most used pharmacologic practice parameter) were published on 29 January
treatments against spasticity at the present. It can 2010. They are based on revising all the existent
be used in all patients with cerebral palsy, having studies between 1966-2008 and the classification
specific indications depending on degree of func- according to the level of scientific proofs according
tional severity (I-V GMFCS). It causes presynaptic to AAN classification [18] and stipulates as follows:
neuromuscular block by preventing the release of “For localized or segmental spasticity, botulinum
acetylcholine at the neuromuscular junction. Botu- toxin type A is effective and generally safe treatment
linum toxin splits the SNAP-25 protein located on (level of evidence A); however, FDA is investigating
the plasma membrane. This causes weakness in the isolated cases of generalized weakness resulting in
poor outcomes.There are insufficient data to support
or reject use of phenol, alcohol or botulinum toxin
type B as regional treatment (level U). For general-
ized spasticity, diazepam should be used for short
term treatment (level B) and tizanidine is possibly
effective (level C). Data were insufficient for use of
dantrolene, oral baclofen, and intrathecal baclofen,
and toxicity was frequently reported (level U)”
2.5 Surgical treatment
The need for surgical treatment depends of the
level of severity, respectively, as the damage is more
severe, the treatment will be used earlier (IV-V
GMFCS level). Its purpose is to reduce spasticity,
correcting the segments alignment in the joint and
preventing bone deformities. In the case of irrevers-
ible deformities, it is recommended reconstruction
Figure 9. Injections with botulinum toxin in gastrocne- to improve function and facilitating the care giv-
mius muscle (Source: Personal archive) ing. They are irreversible treatments with possible

XV, Vol.15, Number 2/2011 149

 Cerebral palsy

5. Alexander MA, Molnar GE. Pediatric Rehabilitation:

complications, and without proof of efficiency. Physical Medicine and Rehabilitation, Philadelphia: Hanley
a) dorsal rhizotomy – uses the cutting of sensi- & Belfus 2000.
tive dorsal roots (L1-5 or T12-L1) which leads to 6. Anttila H, Autti-Ramo I, Suoranta J, Makela M. Ef-
decrease spasticity, but with small functional gain. fectiveness of physical therapy interventions for children with
Main disavantage for this procedure are: the irre- cerebral palsy: a systematic review. BMC Pediatr, 2008;814.
versibility and the side effects: hip dysplasia, spine doi:101186/1471-2431-8-14.
deformation, urinary retention, ileus, and aspiration 7. Jones RB. Vojta method of treating cerebral Palsy.
pneumonia. It was mostly used in 1984-1993. At Physiotherapy, 1975; 65: 112-3.
the present the enthusiasm has lowered. 8. America Academy of pediatrics Policy statement: the
b) Mielotomy used in the 70’s-80’s was aban- Doman-Delacato Treatment of neurologically handicapped
doned at the present due to unpredictability of the children. Pediatrics 1982:70: 810-2.
results and side effects. 9. Liptak GS. Complementary and alternative thera-
c) Musculoskeletal surgical treatment consists pies for cerebral palsy. Ment Retard Dev Disabil Res Rev
in tenotomia, reinserting tendons, correcting hip 2005;11:156-63.
dislocation and spine deformation, osteotomia to 10. Pin T, Dyke P, Chan M. The effectiveness of passive
align the limb segments. stretching in children with cerebral palsy Developmental
Medecine & Child Neurology, 2006;48: 855-62.
d) Stereotaxic surgery of basal ganglia – used
to treat rigidity, choreo-athetosis, tremor; is a new 11. Molenaers G, Desloovere K, Eyssen M. A treatment
of cerebral Palsy: an integrated approach. Eur J Neurol
treatment, very costly, with very good results in
1999,6,(suppl 4.): 51-7.
some cases.
12. Ari S Zeldin, Alicia T F Bazzano, Boosara Ratana-
wongsa. Cerebral Palsy: Treatment & Medication-emedicine
Conclusions Updated: Feb 25, 2010.
Cerebral palsy treatment has to be tailored ac- 13. Content validity of the expanded and revised Gross
cording to the patient’s age, clinical form, severity Motor Function Classification System. Developmental
of the diseases and it involves a multitasking team Medicine & Child Neurology, 50 (10), 744-50.
including the patient’s family. At this moment there 14. Palisano R, Rosenbaum P, Walter S, Russell D, Wood
are available a large number of treatments options E & Galuppi B. (1997). Development and reliability of a
system to classify gross motor function in children with
to chose from. Identifying the right approach needs cerebral palsy. Developmental Medicine & Child Neurology,
an evidence based evaluation to prove the usefulness 39, 214-223.
and superiority of a method over the other and a 15. Thorogood C, Alexander, M. Cerebral Palsy: Treat-
skilled neurologist. ment & Medication - eMedicine, Updated: Mar 11, 2009.
16. Hurst D, Lajara-Nanson WA, Margie E Lance-Fish.
References RN Walking With Modafinil and Its Use in Diplegic Ce-
1. Mutch LW, Alberman E,Hagberg B, Kodama K, Ve- rebral Palsy: Retrospective Review Posted: 07/05/2006;
lickovic MV. Cerebral Palsy epidemiology: where are we now ©  2006  BC Decker, Inc. MEDSCAPE.
and where are we going? Developmental Medecine & Child 17. Lannin N, Scheienberg A, Clark K. AACPDM sys-
Neurology 1992; 34: 547-55. tematic review of the effectiveness of therapy for children
2. Papavasiliou A. Management of motor problems in with cerebral palsy after botulinum toxin A injections De-
Cerebral Palsy: A critical Update for the clinician, European velopmental Medecine & Child Neurology 2006; 48: 533-9.
Journal of Paediatric Neurology 13, (2009) 387-396. 18. Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings
3. Freeman Miller. Cerebral Palsy, Springer Science & busi- DL, McLaughlin J, et al. Practice parameter: pharmacologic
ness media inc. 2005. treatment of spasticity in children and adolescents with cere-
4. Weindling AM, Hallam P, Gregg J, Klenka H, Rosen- bral palsy (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neu-
bloom L, Hutton JL. A randomized controlled trial of early
rology and the Practice Committee of the Child Neurology
physiotherapy for high-risk infants. Acta Paediatrica 1996;
Society. Neurology. Jan 26 2010;74(4):336-43
85: 1107-11.

150 Therapeutics, Pharmacology and Clinical Toxicology