Management of Spastic Cerebral Palsy
Primary Goal of Treatment
The primary goal is to maximize long-term health-related quality of life and social participation through control of spasticity, prevention of structural damage, normalization or preservation of function, and promotion of optimal independence. 1
With appropriate comprehensive management, 2 in 3 individuals with spastic CP will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. 1
Immediate Non-Pharmacological Interventions (Start These First)
Begin range-of-motion exercises immediately upon diagnosis to prevent contracture progression—perform them several times daily in all patients. 2 Early intervention is critical and must begin immediately, as delaying intervention causes harmful, progressively irreversible modifications to muscle and bone growth. 1
- Implement antispastic positioning and proper body alignment to reduce reflex hyperexcitability and prevent fixed contractures. 2
- Apply stretching programs and splinting to maintain joint mobility. 2
- Use serial casting for established contractures that interfere with function. 2
Physical and Occupational Therapy Framework
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. 1
- Therapy must incorporate child-initiated movement, task-specific practice, environmental adaptations, repetitive exercises, and age-appropriate activities with intense and enriched programming. 1
Pharmacological Management Algorithm
For Generalized Spasticity:
Start with oral baclofen as the first-line agent—it is FDA-approved specifically for spasticity and is particularly effective for flexor spasms and concomitant pain. 2, 3 Begin at 5 mg three times daily. 4
- Monitor closely for muscle weakness that could impair residual function, urinary function changes, cognitive effects, and sedation when initiating baclofen. 4
- Tizanidine is an alternative oral agent for generalized spasticity, though it is a short-acting drug reserved for daily activities and times when relief of spasticity is most important. 2, 5
- Dantrolene is another alternative for generalized spasticity. 2
Critical pitfall: Do NOT use benzodiazepines during recovery phases—they impair neurological recovery and cause excessive sedation. 2, 4
Note: The FDA label for baclofen states that "efficacy in cerebral palsy has not been established and, therefore, it is not recommended for these conditions." 3 However, the American Academy of Neurology guidelines explicitly recommend baclofen as first-line therapy for spasticity in CP, and this guideline-based recommendation takes precedence in clinical practice. 2
For Focal Spasticity:
Botulinum toxin injections are the preferred first-line treatment for focal spasticity affecting specific muscle groups, particularly when causing pain, functional impairment, or compromising positioning and skin care. 2, 6 There is sufficient evidence for botulinum toxin A as an effective anti-spasticity treatment in children with CP. 6
Advanced Interventions for Refractory Spasticity
When Oral Medications Fail at Maximum Tolerated Doses:
Intrathecal baclofen via programmable pump delivers medication directly to the spinal cord, requiring only 10% of the systemic dose for equivalent effect. 2 Studies demonstrate that >80% of patients show improvement in muscle tone and >65% have improvement in spasms. 2
CRITICAL WARNING: Do NOT abruptly discontinue intrathecal baclofen—this can be catastrophic and potentially fatal. 2
Neurosurgical Options:
Selective dorsal rhizotomy or dorsal root entry zone lesion may be considered for intractable spasticity causing pain, poor skin hygiene, or functional impairment. 2, 7
Consider surgical correction for severe contractures that restrict movement or cause pain and impede rehabilitation. 2
Essential Surveillance and Prevention of Secondary Complications
Hip Surveillance:
Obtain anteroposterior pelvic radiographs every 6-12 months beginning at age 12 months to prevent hip displacement, which affects 28% of children with cerebral palsy. 1
Pain Management:
Three in four children with CP experience chronic pain—implement a comprehensive pain management strategy, including preemptive analgesia for procedural pain, pharmacological therapy for ongoing pain, and environmental interventions. 1
Epilepsy Management:
For epilepsy (affects 35% of cases): Use standard antiepileptic pharmacological management. 1
Sleep Disorders:
For sleep disturbances (affect 23% of cases): Implement specialist assessments and early treatment before secondary academic and behavioral problems emerge, including sleep hygiene, parental education, spasticity management, melatonin, and gabapentin. 1
Feeding and Nutrition:
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. 1
Vision and Hearing:
Assess vision 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. 1 Provide standard early hearing accommodations. 1
Multidisciplinary Team Structure
Essential team members include: pediatric neurologist, pediatrician, orthopedic surgeon, physical therapist, occupational therapist, psychologist, and education specialist. 1
Key Principle Throughout Treatment
Do NOT neglect non-pharmacological interventions even when medications are effective—physical modalities remain essential throughout treatment. 2