What are the symptoms and management options for a patient with spastic cerebral palsy (CP)?

Symptoms of Spastic Cerebral Palsy

Spastic cerebral palsy presents with four cardinal symptom groups: loss of selective motor control, abnormal muscle tone (hypertonia and hyperreflexia), imbalance between muscle agonists and antagonists, and impaired balance. 1

Core Motor Symptoms

• Muscle hypertonicity and spasticity are the defining features, occurring in 80-85% of all cerebral palsy cases, characterized by velocity-dependent increased resistance to passive movement 2, 3
• Loss of selective motor control manifests as inability to isolate individual muscle movements, resulting in mass flexion or extension patterns rather than refined movements 1
• Hyperreflexia with exaggerated deep tendon reflexes and possible clonus 2
• Imbalance between agonist and antagonist muscles leads to abnormal posturing and movement patterns 1

Secondary Musculoskeletal Complications

• Hip subluxation or dislocation develops from chronic muscle imbalance and spasticity 2
• Equinus deformity (toe-walking) from gastrocnemius-soleus spasticity 2
• Joint contractures progress with growth if spasticity remains untreated, as abnormal tone pulls joints into fixed positions 1
• Hand dysfunction from upper extremity spasticity limiting fine motor skills 2
• Balance problems affecting mobility and increasing fall risk 2

Associated Non-Motor Symptoms

• Cognitive dysfunction occurs in approximately 50% of patients, though 1 in 2 individuals with cerebral palsy have normal intelligence 4, 2
• Epilepsy, particularly drug-resistant epilepsy, commonly co-exists with cerebral palsy 3
• Speech impairment affects approximately 25% of patients (3 in 4 will talk) 4, 2
• Visual and hearing impairment 3
• Feeding and swallowing disorders 3
• Behavioral or emotional problems 2
• Pain associated with spasticity and muscle spasms, contributing to worse quality of life 5

Critical Diagnostic Considerations

• Motor type and topography evolve during the first 2 years of life, so absence of spasticity or normal tone early on does not rule out cerebral palsy 4
• Sudden neurological deterioration is inconsistent with cerebral palsy's non-progressive nature and warrants urgent brain and spinal cord MRI to exclude acute stroke, hemorrhage, spinal cord compression, or hydrocephalus 6
• New onset incontinence and increased spasticity require investigation for urinary tract infection (occurring in 15-60% of neurological patients), urinary retention, or new neurological injury rather than attributing symptoms to "just the cerebral palsy" 6

Functional Impact Assessment

• In high-income countries, 2 in 3 individuals with cerebral palsy will walk, though motor severity predictions should be made cautiously in children younger than 2 years using standardized tools like the Gross Motor Function Classification System 4
• Activity limitations vary from mild to severe, with some patients totally dependent on caregivers for all activities of daily living 3
• Quality of life is significantly impacted by spasticity, poor functionality, and chronic pain 5

Management Framework

Non-Pharmacological Interventions

• Range-of-motion exercises should be initiated immediately to prevent contracture progression 7
• Physical and occupational therapy with antispastic positioning and proper body alignment reduce reflex hyperexcitability 7, 2
• Stretching programs and splinting maintain joint mobility and prevent fixed contractures 7

Pharmacological Treatment

• Botulinum toxin A injections have the most sufficient evidence for treating focal spasticity in cerebral palsy, targeting specific muscles causing contracture 7, 8
• Oral baclofen (starting 5 mg three times daily) is FDA-approved for generalized spasticity, particularly effective for flexor spasms and pain, though use cautiously where spasticity sustains upright posture 6, 7, 8
• Intrathecal baclofen via programmable pump delivers medication directly to the spinal cord for severe, refractory spasticity 7, 8
• Avoid benzodiazepines during recovery phases as they may negatively impact neurological recovery 7

Surgical Options

• Selective dorsal rhizotomy for appropriate candidates with severe spasticity 2, 3
• Orthopedic surgery for fixed contractures and skeletal deformities 2

Critical Pitfalls to Avoid

• Never assume new symptoms represent disease progression, as cerebral palsy is non-progressive by definition; sudden changes require urgent investigation for alternative pathology 6
• Do not delay neuroimaging when acute neurological deterioration occurs, as stroke or spinal cord pathology requires time-sensitive intervention 6
• Monitor closely for muscle weakness when initiating baclofen, as excessive weakness could impair residual function the patient depends on for mobility 7