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
non-progressive disease, appearing on an immature
or developing brain (pre-natal, peri-natal, post-natal
in the first 3-4 years of life).[1] It is associated with:
cognitive, sensitive or/and behavioral impairments
and epilepsy. At this moment there is no cure for
cerebral palsy associated with characteristic motor
or coordination dysfunctions. Therapeutic interven-
tion targets only the symptoms, motor and associ-
ated impairments (co-morbidities).
Cerebral palsy is a life lasting disability and is
one of the most expensive diseases. Final goal of
the treatment is to obtain the maximum functional
potential (ideal), or (more realistic) to insure in-
dependence in daily home, school or community
routine activities for the patients, and the best
quality of life possible.
The objectives of the treatment are: a) decreasing
to the minimum of the muscular contractions and
Ioana Minciu
Prof. Dr. Alexandru Obregia Hospital
10 Şos. Berceni, Sector 4, Bucharest
e-mail: iminciu@yahoo.com
izing muscle tone, and increasing joint mobility;
b) increasing muscular strength on weak muscles;
c) improvement of mobility and gaining motor
functional skills.[2]
From the moment we are communicating the
diagnosis to the parents (and this is done only
when it is certain) we must be aware about the
implications that this has on the family and society.
It is preferable to communicate to the parents only
short term prognosis and to propose realistic thera-
peutic objectives. The family must become a stable
structure to support the purpose of the treatment
“the child must become what he/she can become
according to the circumstances”. [3] Along with the
family, diferent medical specialitists are involved
in cerebral palsy treatment: general practitioner,
pediatrician, neurologist, orthopedist, psychiatrist,
and educational system and community, as well.
There are no treatment guidelines for this dis-
ease, still there are mainly two types of treatment
options: conservative and invasive.
1. Conservative treatment consists in func-
tional therapy or physiotherapy which is the main
therapeutic intervention for the motor and tonus
disorders, occupational therapy, speech therapy and
treatment of swallowing disorders, placing orthosis,
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

Figure 4. Bobath therapy - passive movements in the arms
(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)
normal postures. It should be applied as soon as
possible. There are not enough studies to certify
the benefit or the superiority to other interventions.
There is little evidence regarding the efficacy on
neuromotor development. [6]
Sensory-motor therapy - Rood therapy (devel-
oped in 1950 in USA by Margaret Rood). It is based
on tactile stimulations to facilitate movement with
the purpose of activating autonomic movement, as
it happens with normal postural answers. It is based
on 8 sequences of movements: supine withdrawal,
rolling over, pivot prone, neck co-contraction, elbow
weight bearing, all four limbs weight bearing, stand-
ing, and walking. There are no objective reports on
the efficiency of this method.
Sensory integration therapy – Ayers technique
(developed in 1970 by AJ Ayers) is based on the
integration of sensory feedback to produce motor
146
Cerebral palsy
Figure 6. Vojta therapy - phase 2 of reflex rolling, stimula-
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 7. Vojta therapy - it shows presure points used for
stimulation - reflex crawling, stimulation from ventral posi-
tion ( it combines pressure under tibial external malleolus
and shoulder) (Source: Personal archive)
answers with certain purpose/usefulness. The goal
is that the sensory input followed by adequate mo-
tor answer will lead to the development of higher
cortical motor sensory functions. Typical stimula-
tion includes visual, vestibular, proprioceptive and
tactile stimulation. There are no objective proofs
of its efficacy.
Vojta Therapy (developed between 1950-1960
by dr Vojta) it is used for infants. It is widely used
in Europe and Japan. It uses proprioceptive trigger
points from the body and limbs to initiate reflex
movements that lead to rolling, crawling, etc. It is
done on daily basis by family. [7] (fig 5,6,7)
Patterning therapy Doman-Delacato (developed
in 1960-1970, very used in the past in Philadelphia
Therapeutics, Pharmacology and Clinical Toxicology
Ioana Minciu
region) – is based on the recapitulation theory (dur-
ing the development, immature activities rehearsal
will stimulate to develop higher activities). It needs
many hours of daily work, and it was almost aban-
doned because it did not prove other benefits than
keeping joint mobility. [8]
Peto technique – conductive education (devel-
oped in the 1940-50 by Andrea Peto in Hungary),
for patients that have some useful motor functions,
but are not independent, and is stimulating the gain
of some behaviors that they can perform either
very bad or partially and will be helped until they
acquire this behavior. There are used simple devices
for help (for example a simple ladder) [7, 9 ]
Electrical stimulation therapy has as its purpose
the hypertrophy of muscles and the increase of
muscular strength. It is done usually during the
night, but is possible also during the day with in-
tensity reduced below the level the child can feel
and does not produce muscular contractions. It is
based on the increase of the local blood flow. There
is not enough data regarding its indications and
benefits. Because it is painful, electric stimulation
could be applied only rarely to adolescents and
adults. (figure 8)
Figure 8. Electrostimulation on the anterior tibial muscle
(Source: Personal archive)
Increasing the muscular tone and strength
therapy is used for hypotonic muscles or for the
antagonists of spastic muscles.
Constraint induced therapy is useful for the up-
per limb in hemiplegic patients: - the uninvolved
arm is periodically immobilized in a cast to improve
the use of paralyzed arm. There is no data regard-
ing the age for beginning, the level of disabilities,
duration of the treatment, and also regarding the
long term benefits.
Balance techniques for patients with balance
disturbances/horse ridding therapy
XV, Vol.15, Number 2/2011
Manual or external devices passive stretching
techniques – not even in this case are enough data
to sustain the efficacy of this treatment.[10]
Alternative therapies: acupuncture, massage
and mio-fascial relaxation, reflexology, hyperbaric
oxygen therapy, hydrotherapy.
Studies on alternative therapies, have shown no
difference in the regards of disability, are costly, time
consuming and potentially risky by some authors.[9]
Physical therapy is always associated with
other treatment programs: treatment of swallow-
ing, speech, mastication, and occupational therapy.
1.2 Splinters and devices to bear the weight,
to maintain the position and walk, orthosis can
be used in association with physical therapy – there
is no evidence on the long term benefits regarding
their use.
They are used early in the therapeutic plan
and help preventing or correcting bone and joint
deformities, bearing and stabilization of the body
in some postures to help moving and permit some
activities that otherwise would be limited. Static
orthosis are sustaining the joints, help stretching
spastic muscles, maintain joint mobility and prevent
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
the motor disturbance is high and prevents writing,
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
the therapy will have a precise purpose (i.e. putting
the shoes). For adults, as for teenagers, treatment will
have in sight specific objectives (i.e. driving a car).
Medical treatment of spasticity will take into ac-
count the decrease of muscular tone at the moment
and the place were it disturbs the performances.
We will bear in mind that some spastic muscles
are helping the patient to maintain the weight in
orthostatic position and walking, and that lowering
the tonus of these muscles will lead to the incapac-
ity of the patient to walk.
147
 Cerebral palsy

1.4 Oral medication the fatigue, increasing effort capacity in patients

Oral anti-spastic medication is generally used
rare and limited in time due to side effects and only
for patients with severe functional impairment (III,
IV, V degree Gross Motor Function Classification
System- GMFCS). [13, 14] (table I). Its purpose
is to decrease the tonus and pain, to facilitate the
physical care, positioning and to solve some acute
situations (agitation, sleep disorders, seizures).
with prematurity spastic dyplegia. Modafinil has
shown good effects on spastic hemi and tetra pa-
resis group as well, by decreasing muscular tone,
increasing mobility and reducing pain. [16].
Other oral drugs:
Anti-spastic effects were observed with voltage-
dependent sodium channels blocking medication
(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
drugs, tetrazepam and ketazolam, have fewer side
effects and are used more frequently in adults.
Some α2 adrenergic receptors agonists, tizani-
dine and clonidine hydrochloride inhibit the me-
dullar spasticity by blocking H reflex. Tizanidine
facilitates the inhibiting actions of glycine, reducing
the release of excitatory aminoacides and P sub-
stance and has analgesic effects.[15]
Recent studies have shown benefits in cerebral
palsy treatment with Modafinil, a CNS stimulant,
which has decreasing effect on spasticity and good
effect on achieving or improving walking, reducing
148
(ciproheptadin). Regarding ciclobenzapine, studies
have shown low effects on spasticity.
For difficult to treat chorea and athetosys, were
tried benzodiazepines, neuroleptics (ex. haloperi-
dol), anti-parkinsonian (ex. levodopa), anti-cholin-
ergic drugs. Anti-cholinergic drugs are useful in
reducing rigidity, akinesia, tremor and over-drooling
(trihexifenidil initial dose of 1-2 mg/day in adults,
increased with 2 mg/day at 3-5 days up to 4-15
mg/day divided in 3-4 intakes.)[15].
2. Invasive procedures
2.1 Intrathecal administrated medication
For first time Baclofen was administrated intra-
Therapeutics, Pharmacology and Clinical Toxicology
Ioana Minciu
thecal in 1984, and FDA approved it for spasticity
in cerebral palsy treatment in 1992 for adults and
only in 1997 for children. It’s a reversible proce-
dure. It is used for patients with severe dysfunction:
(III) IV-V degree GMFCS [2, 3] with spasticity or
dystonia of cerebral or spinal cause, generalized,
significantly interfering with movement, positioning,
or which give pain and joint deformity. It consists
from a programmable pump, surgically placed under
the abdominal skin or under the external oblique
aponeurosis with a reservoir attached to a catheter
going to the subarachnoid space of spinal channel
at lumbar or thoracic level (usually T6-7). Useful
dose is 100-200 μg/day.
Baclofen is acting through diffusion at superfi-
cial layers of gray matter of the spine were GABA
receptors are located. The strengths in CSF is 10
times larger then after oral administration. Side ef-
fects: respiratory distress, infection at the catheter
or pump site, mechanical problems of the catheter
or pump.
2.2 Injury of motor peripheral nerves by
chemical disconnection
Local injection of alcohol or phenol was mostly
used in the 70’s, today are almost abandoned be-
cause there are toxic, very painful (they are done
with general anesthesia), the effect of decreasing
the spasticity persist for 1-3 month for alcohol and
18-24 month for phenol.
2.3 Local injections in the muscles with botu-
linum toxin is one of the most used pharmacologic
treatments against spasticity at the present. It can
be used in all patients with cerebral palsy, having
specific indications depending on degree of func-
tional severity (I-V GMFCS). It causes presynaptic
neuromuscular block by preventing the release of
acetylcholine at the neuromuscular junction. Botu-
linum toxin splits the SNAP-25 protein located on
the plasma membrane. This causes weakness in the
Figure 9. Injections with botulinum toxin in gastrocne-
mius muscle (Source: Personal archive)
XV, Vol.15, Number 2/2011
muscle into which botulinum toxin type A (ab-
breviated BoNT-A) is injected. Therapeutic effects
may last 3-6 months. You can repeat the injection
but not earlier than 4 months to prevent antibody
development. (fig 9.)
It is used in association with physiotherapy and
orthosis, and it is useful in localized spasticity (2-4
muscles at most), or in dystonia. Commercial names
for the botulinum toxin are Dysport or Botox.[17] .
For I-III GMFCS level of spasticity, the main scope
is to reduce muscular hypertonia and the imbalance
of flexing-extending muscles, allowing the passive
adjustment of the joints’ limbs, elongation of spastic
muscles, better tolerance at wearing orthosis and
preventing or delaying the induction of abnormal
muscle contracture. For IV-V GMFCS level, the
main scope is not functional improvement, but to
facilitate the care giving, reducing pain, wearing the
orthosis, controling the drooling. Adverse events
associated with botulinum toxin use are: asthenia,
generalized muscle weakness, diplopia, blurred
vision, ptosis, dysphagia, dysphonia, dysarthria,
urinary incontinence, and breathing difficulties.
2.4 Alcohol and phenol injections in the
muscles was abandoned nowadays, as it’s already
, mentioned, and more over, large quantity of this
substances are producing muscular fibrosis.
The recommendations of American Academy of
Neurology and Pediatric Neurology Society, regard-
ing the spasticity treatment in cerebral palsy (a new
practice parameter) were published on 29 January
2010. They are based on revising all the existent
studies between 1966-2008 and the classification
according to the level of scientific proofs according
to AAN classification [18] and stipulates as follows:
“For localized or segmental spasticity, botulinum
toxin type A is effective and generally safe treatment
(level of evidence A); however, FDA is investigating
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
to improve function and facilitating the care giv-
ing. They are irreversible treatments with possible
149

complications, and without proof of efficiency.
a) dorsal rhizotomy – uses the cutting of sensi-
tive dorsal roots (L1-5 or T12-L1) which leads to
decrease spasticity, but with small functional gain.
Main disavantage for this procedure are: the irre-
versibility and the side effects: hip dysplasia, spine
deformation, urinary retention, ileus, and aspiration
pneumonia. It was mostly used in 1984-1993. At
the present the enthusiasm has lowered.
b) Mielotomy used in the 70’s-80’s was aban-
doned at the present due to unpredictability of the
results and side effects.
c) Musculoskeletal surgical treatment consists
in tenotomia, reinserting tendons, correcting hip
dislocation and spine deformation, osteotomia to
align the limb segments.
d) Stereotaxic surgery of basal ganglia – used
to treat rigidity, choreo-athetosis, tremor; is a new
treatment, very costly, with very good results in
some cases.
Conclusions
Cerebral palsy treatment has to be tailored ac-
cording to the patient’s age, clinical form, severity
of the diseases and it involves a multitasking team
including the patient’s family. At this moment there
are available a large number of treatments options
to chose from. Identifying the right approach needs
an evidence based evaluation to prove the usefulness
and superiority of a method over the other and a
skilled neurologist.
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Therapeutics, Pharmacology and Clinical Toxicology