What is the recommended management approach for adults with cerebral palsy?

Management of Cerebral Palsy in Adults

Adults with cerebral palsy require a multidisciplinary rehabilitation approach focused on maintaining motor function, preventing secondary musculoskeletal complications, and managing chronic pain, with physiotherapy remaining the cornerstone intervention despite declining accessibility and intensity after adolescence. 1, 2

Core Management Framework

The management of adults with CP must address the reality that while the initial neurological injury is non-progressive, adults commonly develop severe pain (affecting 75%), chronic fatigue, and premature decline in mobility and function as they age. 1, 3 The primary goals are to maintain motor function, prevent secondary complications, and manage pain—not to achieve new motor milestones. 1

Motor Rehabilitation Services

Physiotherapy should be delivered regularly in outpatient settings, though accessibility becomes a major barrier in adulthood. 2 The French ESPaCe survey demonstrated that finding an available physiotherapist was very difficult for almost half of children and an even greater proportion of adults with CP. 2

• Physical therapy intensity decreases sharply after age 18, with weekly sessions declining as care shifts from multidisciplinary centers to private outpatient practices. 2
• Adults over 25 receive physiotherapy in private outpatient settings at twice the rate of children and adolescents, but with reduced frequency and multidisciplinary support. 2
• Task-specific, motor training-based interventions that were effective in childhood (CIMT for hemiplegia, GAME for all subtypes) should be adapted and continued into adulthood to maintain neuroplasticity and functional gains. 4, 1

Prevention of Secondary Musculoskeletal Complications

Hip surveillance must continue beyond childhood, with regular monitoring for hip displacement, which affects 28% of individuals with CP. 1 Adults are at ongoing risk for progressive contractures, scoliosis, and abnormal bone growth that interfere with function. 5

• Implement regular surveillance protocols with clinical examination and imaging as needed to detect early contracture development and bone deformities. 1, 5
• Bracing and orthotic management should be adjusted as musculoskeletal changes occur. 5
• Orthopedic surgical interventions may be necessary when conservative management fails to maintain function or prevent pain. 5

Pain Management

Chronic pain affects three in four adults with CP and requires a comprehensive management strategy. 1 This is the most common and debilitating secondary complication in adults. 3

• Implement pharmacological therapy for ongoing pain, including standard analgesics and neuropathic pain medications. 1
• Environmental interventions and activity modifications to reduce pain triggers. 1
• Spasticity management through oral medications (baclofen, tizanidine), neurolytic blocks (botulinum toxin, phenol), or neurosurgical procedures (intrathecal baclofen pumps, selective dorsal rhizotomy) when spasticity contributes to pain or functional decline. 5

Neurological Management

For epilepsy (present in 35% of adults with CP), continue standard antiepileptic pharmacological management with regular monitoring. 1 Seizure control may change with age and require medication adjustments. 1

Sleep Disorders

Sleep disturbances affect 23% of adults with CP and require specialist assessment and treatment. 1 Management includes:

• Sleep hygiene education and environmental modifications. 1
• Spasticity management, as nocturnal spasms frequently disrupt sleep. 1
• Pharmacological interventions including melatonin and gabapentin. 1

Fatigue Management

Chronic fatigue is a major complaint in adults with CP and contributes to functional decline. 3 Address through:

• Energy conservation techniques and activity pacing strategies
• Assessment and treatment of contributing factors (pain, sleep disorders, depression)
• Graded exercise programs adapted to individual capacity 6

Complementary Approaches

Recreational sports, yoga, and meditation may provide benefits for stress reduction, pain management, and maintaining fitness in adults with CP. 6 While evidence is limited, national surveys document that a majority of adults with chronic disabilities use complementary methods and report relief of pain, reduced stress and anxiety, and improved feelings of well-being. 6

• These activities allow adults to take charge of their own healthcare decisions and feel more in control than with traditional methods alone. 6
• Hippotherapy and aquatic therapy may be continued from childhood into adulthood for both physical and psychological benefits. 6

Critical Transition Period

The transition from pediatric to adult care (ages 12-25) represents a vulnerable period where multidisciplinary rehabilitation decreases sharply and satisfaction with rehabilitation programs declines. 2

• Multidisciplinary rehabilitation is halved at adulthood compared to childhood. 2
• Adolescents should be considered a specific population requiring targeted transition planning, not simply grouped with either children or adults. 2
• Perceived impact of physiotherapy on individuals with CP and their caregivers becomes less positive during adolescence. 2

Essential Multidisciplinary Team

The adult care team should include a neurologist, physiatrist, orthopedic surgeon, physical therapist, occupational therapist, pain specialist, and psychologist. 1, 5 This mirrors the pediatric team structure but with adult-focused expertise. 1

Common Pitfalls to Avoid

• Do not assume that adults with CP no longer need rehabilitation services—functional decline and secondary complications are progressive without ongoing intervention. 3, 2
• Do not discontinue hip surveillance and contracture monitoring after skeletal maturity—these complications continue to develop in adulthood. 1
• Do not underestimate the impact of chronic pain—it is the most common secondary complication and requires proactive management. 1, 3
• Do not rely solely on private outpatient physiotherapy without multidisciplinary support—this model is associated with reduced therapy intensity and poorer outcomes. 2