Management of Cerebral Palsy
Cerebral palsy requires immediate initiation of early, task-specific, motor training-based interventions upon diagnosis or high suspicion, combined with systematic surveillance and management of comorbidities through a multidisciplinary team approach. 1, 2
Core Management Principles
Early intervention is critical and must begin immediately upon diagnosis or suspicion of cerebral palsy—delaying intervention causes harmful, progressively irreversible modifications to muscle and bone growth. 2 Infants who do not actively use their motor cortex risk losing cortical connections and dedicated function. 2
The three primary goals guiding all management are: 2
- Optimize motor, cognition, and communication outcomes
- Prevent secondary impairments
- Support parent/caregiver mental health
Motor Rehabilitation Framework
Evidence-Based Interventions
For motor rehabilitation, implement constraint-induced movement therapy (CIMT) for hemiplegia and Goals-Activity-Motor Enrichment (GAME) for all CP subtypes, delivered in home-based settings whenever possible. 2
Physical and occupational therapy must incorporate: 2
- Child-initiated movement
- Task-specific practice
- Environmental adaptations
- Repetitive exercises
- Age-appropriate activities
- Intense and enriched programming (home-based programs produce better outcomes than clinic-based approaches)
Systematic Surveillance and Prevention of Secondary Complications
Musculoskeletal Monitoring
Hip surveillance: Obtain anteroposterior pelvic radiographs every 6-12 months beginning at age 12 months. 3, 2 This prevents hip displacement, which affects 28% of children with cerebral palsy. 1
Contracture prevention: Implement regular surveillance and early intervention to reduce rates of contracture and scoliosis, particularly in bilateral CP. 2
Pain Management
Three in four children with CP experience chronic pain—implement a comprehensive pain management strategy. 3, 2 This includes:
- Preemptive analgesia for procedural pain (untreated procedural pain elevates risk for long-term neuropathic pain) 3
- Pharmacological therapy for ongoing pain 3
- Environmental interventions 3
Neurological Management
For epilepsy (affects 35% of cases): Use standard antiepileptic pharmacological management. 3, 1 Monitor clinical state and EEG at regular intervals, as deterioration in seizure control has been reported occasionally in patients taking baclofen. 4
Sleep Disorders
For sleep disturbances (affect 23% of cases): Implement specialist assessments and early treatment before secondary academic and behavioral problems emerge. 3, 1 Interventions include:
Feeding and Nutrition
For feeding concerns: Comprehensively assess swallowing safety if concerns exist or if there is clinical history of pneumonia, as pneumonia is the leading cause of death in individuals with cerebral palsy and is mitigated by tube feeding. 3 Weight should be measured regularly because severe physical disability elevates risk for malnutrition. 3
Sialorrhea Management
For excessive drooling: Consider botulinum toxin A, benztropine mesylate, or glycopyrrolate. 3 Note that botulinum toxin products carry a boxed warning regarding distant spread of toxin effects, which can cause life-threatening swallowing and breathing difficulties. 5
Vision and Hearing
Vision: Assess in the first 48 hours of life; any infant with abnormal vision at term-equivalent age should receive vision intervention and be reassessed at 3 months. 3 Visual impairment affects 11% of cases. 1
Hearing: Provide standard early hearing accommodations. 3 Hearing impairment affects 4% of cases. 1
Urinary Tract
Conduct medical investigations for bladder function, as abnormal anatomical findings are common. 3 Provide standard toilet training over a longer duration, as control may take longer. 3
Spasticity Management
Pharmacological Options
Oral baclofen: Use with caution where spasticity is utilized to sustain upright posture and balance in locomotion. 4 Patients should be cautioned regarding sedation and operation of automobiles or dangerous machinery. 4 A dose-related increase in ovarian cysts has been observed in female rats treated chronically with baclofen. 4
Neurosurgical Interventions
Selective dorsal rhizotomy (SDR): Consider for selected children with spastic cerebral palsy, particularly those with lower limb spasticity. 6, 7 When combined with physiotherapy, SDR is effective in selected children and has minimal complications. 6 The single-level laminectomy technique at the conus utilizing intraoperative EMG is minimally invasive. 6
Intrathecal baclofen pump placement: May be considered for tone management in select individuals. 7
Orthopedic surgery: Has an important role in treating musculoskeletal deformities and contractures by lengthening musculotendinous structures, transferring tendons, performing osteotomies, and normalizing rotation. 7
Multidisciplinary Team Structure
Essential team members include: 2
- Pediatric neurologist
- Pediatrician
- Orthopedic surgeon
- Physical therapist
- Occupational therapist
- Psychologist
- Education specialist
The combined approach of managing tone and normalizing biomechanics through orthopedic surgery, neurosurgery, and subsequent rehabilitation is the cornerstone of treatment. 7
Cognitive and Behavioral Management
Intellectual disability affects 49% of cases and behavioral disorders affect 26%. 1 Comprehensive neuropsychological assessment and appropriate educational interventions are essential. 2
Expected Outcomes with Appropriate Management
With early intervention and comprehensive management: 1, 2, 8
- 2 in 3 individuals with CP will walk
- 3 in 4 will talk
- 1 in 2 will have normal intelligence
Critical Pitfalls to Avoid
Never delay diagnosis waiting for certainty—use an interim diagnosis of "high risk of cerebral palsy" if definitive diagnosis cannot yet be made. 1 Delaying diagnosis and appropriate management is harmful to parent and caregiver well-being, potentially leading to depression and lasting anger. 1
Do not wait for motor milestone achievement before initiating intervention—early intervention maximizes neuroplasticity during the critical developmental window. 2
Ensure lifelong surveillance with individualized rehabilitation plans updated regularly based on developmental milestone progress. 2