Management and Treatment of Cerebral Palsy
Begin intensive, task-specific motor interventions immediately upon diagnosis or high suspicion of cerebral palsy—delaying treatment causes progressively irreversible modifications to muscle and bone growth that become exponentially harder to reverse over time. 1
Early Diagnosis Framework
Diagnose cerebral palsy as early as possible, ideally before 5 months corrected age, to capitalize on maximal neuroplasticity. 2, 1 Use an "interim diagnosis of high risk of CP" when certainty is lacking but suspicion exists—this allows immediate intervention while monitoring continues, avoiding the harmful delays that occur when waiting for diagnostic certainty. 1
Before 5 months corrected age, use these standardized tools with highest predictive accuracy:
- Term-age MRI (86-89% sensitivity) 2, 3
- Prechtl Qualitative Assessment of General Movements (98% sensitivity) 2, 3
- Hammersmith Infant Neurological Examination (90% sensitivity) 2, 3
After 5 months corrected age, the most predictive tools are:
- MRI (86-89% sensitivity) 2
- Hammersmith Infant Neurological Examination (90% sensitivity) 2
- Developmental Assessment of Young Children (83% C index) 2
Motor Rehabilitation: The Core Intervention
Start constraint-induced movement therapy (CIMT) for hemiplegia or Goals-Activity-Motor Enrichment (GAME) for all cerebral palsy subtypes immediately upon diagnosis. 1, 4 These interventions must incorporate child-initiated movement, task-specific practice, environmental adaptations, repetitive exercises, and age-appropriate activities with intense and enriched programming. 4
Deliver interventions in home-based settings whenever possible—home programs produce superior motor and cognitive outcomes compared to clinic-based approaches. 1, 4 This is a critical implementation detail that directly impacts morbidity and quality of life.
Physical and occupational therapy should be intensive, frequent, and focused on functional goals rather than passive stretching or positioning alone. 4
Systematic Surveillance Protocol for Secondary Complications
Hip Surveillance
Obtain anteroposterior pelvic radiographs every 6-12 months starting at age 12 months to prevent hip displacement, which affects 28% of children with cerebral palsy. 1, 4, 3 Early detection allows intervention before irreversible joint damage occurs, directly impacting long-term mobility and pain levels.
Pain Management
Three in four children with cerebral palsy experience chronic pain. 4 Implement preemptive analgesia for all procedural pain—untreated procedural pain elevates risk for long-term neuropathic pain. 1 Use comprehensive pain management including pharmacological therapy for ongoing pain and environmental interventions. 4
Contracture and Scoliosis Prevention
Implement regular surveillance and early intervention to reduce contracture and scoliosis rates, particularly in bilateral cerebral palsy. 1, 4 For foot drop in hemiplegic cerebral palsy, prescribe ankle-foot orthosis (AFO) immediately to improve gait mechanics and prevent contractures. 1
Management of Common Comorbidities
Epilepsy (affects 35% of cases)
Use standard antiepileptic pharmacological management according to seizure type and severity. 1, 4, 3
Sleep Disorders (affect 23% of cases)
Conduct specialist assessments and treat sleep disorders before secondary academic and behavioral problems emerge. 1, 4 Implement sleep hygiene, parental education, spasticity management, melatonin 2.5-10 mg, and gabapentin 5 mg/kg. 1
Feeding and Nutrition
Comprehensively assess swallowing safety if pneumonia history exists or feeding concerns arise—pneumonia is the leading cause of death in cerebral palsy and is mitigated by tube feeding when indicated. 1, 4, 3 Do not delay gastrostomy tube placement when swallowing dysfunction is documented, as aspiration pneumonia directly impacts mortality.
Vision and Hearing
Assess vision in first 48 hours of life; any infant with abnormal vision at term-equivalent age requires vision intervention and reassessment at 3 months. 1, 4 Provide standard early hearing accommodations for the 4% with hearing impairment. 1, 3
Cognitive and Behavioral Issues
Intellectual disability affects 49% and behavioral disorders affect 26% of cases. 4, 3 Comprehensive neuropsychological assessment and appropriate educational interventions are essential for optimizing quality of life. 4
Spasticity Management Options
For moderate to severe spasticity interfering with function or causing pain:
- Intramuscular onabotulinumtoxinA for focal spasticity 5
- Systemic muscle relaxants (oral baclofen, diazepam) for generalized spasticity 5
- Intrathecal baclofen pump for severe generalized spasticity 5
- Selective dorsal rhizotomy for carefully selected children with spastic diplegia who have good underlying strength and minimal fixed contractures 6, 5
Multidisciplinary Team Structure
Essential team members include: pediatric neurologist, pediatrician, orthopedic surgeon, physical therapist, occupational therapist, psychologist, and education specialist. 1, 4 An integrated effort coordinator (typically the primary physician) is essential when a specialized multidisciplinary clinic is unavailable. 7
Family Support and Mental Health
Screen parental mental health routinely—1 in 4 children have behavior disorders that compound parental stress, anxiety, and depression. 1 Provide immediate counseling and goal-setting with parents at intervention start to reduce depression and anger. 1 Delaying diagnosis and appropriate management can be harmful to parent and caregiver well-being, potentially leading to lasting anger toward the medical team. 3
Expected Outcomes with Appropriate Management
With early intervention and comprehensive management: 2 in 3 individuals will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. 2, 1, 4, 3 These outcomes emphasize that cerebral palsy, while permanent, is highly amenable to intervention that meaningfully improves quality of life and functional independence.
Critical Pitfalls to Avoid
Never delay intervention while awaiting diagnostic certainty—use "high risk of CP" diagnosis to start treatment immediately, as standardized tools have less than 5% false positive rate. 1 False negatives resulting in late diagnosis are far more detrimental to parents, caregivers, and infants than false positives. 1
Do not rely solely on clinic-based therapy—home-based programs are superior for motor and cognitive outcomes. 1
Avoid undertreating procedural pain, as this creates long-term neuropathic pain risk that significantly degrades quality of life. 1
Do not wait to address hip surveillance, feeding dysfunction, or sleep disorders—these secondary complications become progressively more difficult to manage and directly impact morbidity and mortality. 1, 4