From the Guidelines
The management of spasticity in cerebral palsy involves a multimodal approach combining physical therapy, oral medications, focal interventions, and surgical options, with botulinum toxin injections being a recommended treatment for patients with focal spasticity that is painful, impairs function, or compromises proper positioning or skin care, as supported by recent guidelines 1. The foundation of treatment includes physical therapy, with stretching, positioning, and strengthening exercises to maintain range of motion and prevent contractures. First-line oral medications include baclofen, diazepam, and dantrolene sodium, with dosages adjusted based on patient response and tolerance. For focal spasticity, botulinum toxin injections are recommended, providing temporary relief lasting 3-6 months, as evidenced by studies 1. Intrathecal baclofen therapy, delivered via an implanted pump, is effective for severe, diffuse spasticity, and orthopedic surgeries like selective dorsal rhizotomy or tendon lengthening procedures may be considered for permanent spasticity reduction. Treatment selection depends on spasticity distribution, functional goals, and side effect profiles, with the aim of improving mobility, reducing pain, facilitating care, and enhancing quality of life by addressing the underlying neurological hyperexcitability that causes muscle tone abnormalities in cerebral palsy. Some studies suggest that other interventions, such as neuromuscular electrical stimulation, virtual reality, and acupuncture, may have variable effects or insufficient evidence to support their use in spasticity management 1. However, the use of botulinum toxin for focal spasticity is supported by strong evidence, making it a key component of spasticity management in cerebral palsy, as recommended by recent guidelines 1. In contrast, older guidelines, such as those from 2016 1, may provide additional context but are superseded by more recent evidence and recommendations. Key considerations in spasticity management include the potential benefits and limitations of each treatment option, as well as the importance of individualizing treatment to each patient's unique needs and circumstances. Ultimately, effective management of spasticity in cerebral palsy requires a comprehensive and multidisciplinary approach, incorporating the latest evidence and guidelines to optimize patient outcomes, as supported by recent studies 1.
From the Research
Management of Spasticity in Cerebral Palsy
The management of spasticity in cerebral palsy is complex and requires a multidisciplinary approach 2, 3, 4, 5, 6.
- Selective Dorsal Rhizotomy (SDR): SDR is a neurosurgical technique that aims to reduce spasticity in the lower limbs 2, 3, 6.
- Botulinum Toxin A: Botulinum toxin A is a relatively long-lasting, easy to administer, reversible, and has a favourable side-effect profile, making it highly useful for focal spasticity 4, 5.
- Intrathecal Baclofen: Intrathecal baclofen has an emerging role in the management of spasticity in cerebral palsy 4, 6.
- Orthopaedic Surgery: The use of orthopaedic surgery has significantly altered in recent years and is still a valuable option in the management of spasticity in cerebral palsy 4.
- Physical Therapy: Physical therapy plays a critical role in defining disability, assessing function, undertaking biomechanical assessment, and providing mobility aids/casting/orthoses and motor training/stretching exercises 4, 5.
Multidisciplinary Approach
A multidisciplinary approach is essential in the management of spasticity in cerebral palsy, requiring a team of physicians, physiotherapists, and other healthcare professionals to choose the best treatment for each child in each developmental period 3, 5.
- Team Work: A multidisciplinary team can significantly improve the quality of life of patients with cerebral palsy by providing a comprehensive and structured approach to management 3, 5.
- Patient Selection: Appropriate patient selection is imperative, and treatment goals need to be well defined and tailored to the individual patient's needs 5.
- Continuous Reassessment: Growth and development is a continuous and evolving process, necessitating the constant reassessment of the patient and modification of future treatment goals 5.