What are the management options for cerebral palsy?

Management of Cerebral Palsy

Task-specific, motor training-based early intervention (such as GAME and CIMT) should be initiated immediately upon diagnosis or suspicion of cerebral palsy to maximize neuroplasticity and functional outcomes, combined with systematic surveillance and management of common comorbidities that affect three-quarters of patients. 1

Core Principles of Management

The management approach must address three primary goals simultaneously 1:

• Optimize motor, cognition, and communication outcomes through interventions that promote neuroplasticity (all patients have motor impairments, 50% have intellectual disability, 25% are nonverbal) 1
• Prevent secondary impairments that worsen function or interfere with learning 1
• Support parent and caregiver mental health to reduce stress, anxiety, and depression 1

Early Intervention Strategies (Primary Motor and Cognitive Optimization)

Motor and Cognitive Interventions

Physical and occupational therapy must use child-initiated movement, task-specific practice, and environmental adaptations 1:

• For hemiplegic cerebral palsy: Constraint-Induced Movement Therapy (CIMT) or bimanual training produces better hand function in both short and long-term outcomes 1
• For diplegic cerebral palsy: Learning Games Curriculum is recommended 1
• For all subtypes: Goals-Activity-Motor Enrichment (GAME) intervention—an early, intense, enriched, task-specific training-based intervention delivered at home—produces better motor and cognitive skills at 1 year compared to usual care 1

Critical timing consideration: Early active movement and intervention are essential because infants who do not actively use their motor cortex risk losing cortical connections and dedicated function 1

Communication Interventions

Speech-language pathology interventions should foster parent-infant transactions and provide compensation when speech is inadequate 1:

• Hanen "It Takes Two to Talk" and "More Than Words" programs are recommended 1
• Alternative and augmentative communication should be provided when speech is not possible or inadequate 1

Management of Secondary Complications and Comorbidities

Pain Management (Affects 75% of Patients)

Procedural pain must be avoided where possible because untreated pain elevates risk for long-term neuropathic pain 1:

• Pharmacological therapy and environmental interventions for ongoing pain 1
• Preemptive analgesia for procedural pain 1

Orthopedic Surveillance (Hip Displacement Affects 28% of Patients)

Anteroposterior pelvic radiographs every 6 to 12 months starting at age 12 months are mandatory for hip surveillance 1

This prevents hip displacement, contracture, and scoliosis, which occur at lower rates with regular surveillance and intervention 1

Neurologic Management (Epilepsy Affects 35% of Patients)

Standard antiepileptic pharmacological management is recommended for seizure control 1

Urinary Tract Management (Bladder Control Problems Affect 25% of Patients)

• Medical investigations should be conducted because abnormal anatomical findings are common 1
• Standard toilet training over a longer duration because control may take longer 1

Sleep Disorders (Affect 20% of Patients)

Specialist assessments and early treatment before secondary academic and behavioral problems emerge 1:

• Sleep hygiene and parental education 1
• Spasticity management 1
• Melatonin 2.5–10 mg 1
• Gabapentin 5 mg/kg 1

Sialorrhea Management (Affects 20% of Patients)

Consider the following pharmacological options 1:

• Botulinum toxin A 1
• Benztropine mesylate 1
• Glycopyrrolate 1

Vision Management (Visual Impairment Affects 10% of Patients)

• Vision can be assessed in the first 48 hours of life using early assessment tools 1
• Any infant with abnormal vision at term-equivalent age should receive vision intervention and be reassessed at 3 months 1

Feeding and Nutrition Management (Tube Feeding Required in 7% of Patients)

Swallowing safety must be comprehensively assessed if concerns or clinical history of pneumonia exists because pneumonia is the leading cause of death in individuals with cerebral palsy and is mitigated by tube feeding 1

• Weight should be measured regularly because severe physical disability elevates risk for malnutrition 1

Hearing Management (Hearing Impairment Affects 4% of Patients)

Standard early hearing accommodations are recommended 1

Evidence-Based Therapeutic Interventions

Additional effective interventions supported by systematic review evidence 2:

• Acceptance and commitment therapy 2
• Action observations and bimanual training 2
• Casting (alone or combined with botulinum toxin) 2
• Environmental enrichment and fitness training 2
• Goal-directed training and hippotherapy 2
• Home programs and mobility training 2
• Strength training and task-specific training 2
• Treadmill training with or without partial body weight support 2

Medical and Surgical Interventions

Effective medical and surgical options 2:

• Botulinum toxin (alone or combined with occupational therapy or casting) 2
• Intrathecal baclofen for spasticity management 2
• Diazepam for muscle relaxation 2
• Bisphosphonates for bone health 2
• Selective dorsal rhizotomy for appropriate candidates 2
• Scoliosis correction when indicated 2
• Hip surveillance programs to prevent displacement 2

Common Pitfalls to Avoid

Delaying intervention until definitive diagnosis: Early intervention should begin as soon as cerebral palsy is suspected, using the interim diagnosis of "high risk of cerebral palsy" if needed 1, 3

Waiting beyond age 2 years for diagnosis: Clinical signs emerge and evolve before age 2 years, and false negatives resulting in late diagnoses are detrimental to parents, caregivers, and infants 1, 3

Ignoring parental concerns: 86% of parents suspect cerebral palsy before clinical diagnosis is made, and seeking to avoid false-positive results by delaying diagnosis is harmful to parent and caregiver well-being 3

Inadequate pain management: Untreated procedural pain creates long-term neuropathic pain risk 1

Missing hip surveillance: Regular radiographic monitoring prevents the 28% risk of hip displacement 1, 4

Prognosis and Functional Outcomes

In high-income countries, population data indicate 5, 3, 4:

• 2 in 3 individuals with cerebral palsy will walk 5, 3, 4
• 3 in 4 will talk 5, 3, 4
• 1 in 2 will have normal intelligence 5, 3, 4

Motor function classification may change during the first 2 years of life, with approximately half of infants having their GMFCS level reclassified 5