Cerebral Palsy

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Treatment

A multidisciplinary team of health care professionals develops an individualized treatment plan based on the patient's needs and problems. It is imperative to involve patients, families, teachers, and caregivers in all phases of planning, decision making, and treatment.

A pediatrician, pediatric neurologist, or pediatric physiatrist (physician who specializes in physical medicine) provides primary care for children with CP. A family doctor, neurologist, or physiatrist provides primary care for adults with CP.

The primary care provider gathers input from the health care team, synthesizes the information into a comprehensive treatment plan, and follows the patient's progress. Other specialists on the team may include:

• Orthopedist or orthopedic surgeon to predict, diagnose, and treat associated muscle, tendon, and bone problems
• Physical therapist to design and supervise special exercise programs for improving movement and strength
• Speech and language pathologist to diagnose and treat communication problems
• Occupational therapist to help the patient learn life skills for home, school, and work
• Social worker to help patients and their families obtain community assistance, education, and training programs
• Psychologist to help address negative or destructive behaviors, and guide the patient and his/her family through the stresses and demands presented by cerebral palsy

The need for and types of therapy change over time. Adolescents with CP may need counseling to cope with emotional and psychological challenges. Physical therapy may be supplemented with special education, vocational training, recreation, and leisure programs.

Adults may benefit from attendant care, special living accommodations, and transportation and employment assistance services, depending upon his or her intellectual and physical capabilities.

Physical Therapy
It is important for physical therapy to begin soon after diagnosis is made. Daily range of motion exercises help prevent muscles from growing weak and atrophied or rigidly fixed from contracture.

Normally, muscles and tendons stretch and grow at the same rate as bones. Spasticity can prevent stretching, and muscle growth may not keep up with bone growth. The muscles can become fixed in stiff, abnormal positions. Physical therapy, often in combination with special braces, helps prevent contracture by stretching spastic muscles. It also can improve a child's motor development.

To prepare a child for school, the focus of therapy gradually shifts toward activities associated with daily living and communication. Exercises are designed to improve the child's ability to sit, move independently, and perform tasks such as dressing, writing, and using the bathroom.

Orthotics can help control limb position, and walkers can help some patients walk. Mastering such skills reduces demands on caregivers and helps the child obtain some degree of self-reliance, which helps build self-esteem.

Speech therapy
Children with athetoid (dyskinetic) CP often have trouble pronouncing words (dysarthria), and swallowing (dysphagia). Difficulty with swallowing causes eating problems and drooling.

Speech therapy can help improve swallowing and communication. A speech therapist also can work with the child to learn to use special communication devices like computers with voice synthesizers.

Psychotherapy
Behavioral therapy can complement physical therapy, employing psychological techniques that encourage the mastery of tasks that promote muscular and motor development. Praise, positive reinforcement, and small rewards can encourage a child to learn to use weak limbs, overcome speech deficits, and stop negative behaviors like hair pulling and biting.

Medication
As with many forms of drug therapy, a certain amount of experimentation may be required before optimum results are achieved.

Seizures—No single drug controls all types of seizures, and no two patients respond identically to any given drug. Medications are divided into first-generation anticonvulsants (older medications) and second-generation anticonvulsants (more recently developed).

Spasticity—The muscle relaxants diazepam (Valium®) and dantrolene (Dantrium®) may be prescribed to control muscle contraction (myoclonus). These drugs reduce spasticity for short periods, and their long-term value is uncertain. The long-term effect of these drugs on a child's developing nervous system is unknown.

Side effects of diazepam include drowsiness, slurred speech, constipation, nausea, and incontinence. Common side effects of dantrolene include drowsiness, dizziness, general weakness, and diarrhea.

The most common side effect of phenobarbitol is drowsiness. Other effects include dizziness, slowed heart rate, confusion, constipation, and nausea. Phenobarbitol and the other barbiturates can become habit forming.

Baclofen is a muscle relaxant and antispastic medication that is available in tablet and injectable forms. Intrathecal baclofen uses a very small implanted pump to deliver a steady supply of medication into the fluid around the spinal cord. Strict compliance with the refill schedule is imperative to avoid abrupt withdrawal and resulting severe complications, including death.

Side effects associated with baclofen include confusion, dizziness, drowsiness, headache, insomnia, nausea, hypotension, and urinary frequency.

Anticholinergics may be prescribed to control the abnormal movements associated with athetoid cerebral palsy. These drugs inhibit the effects of acetylcholine, a chemical in brain cells that triggers muscle contraction. The most commonly prescribed anticholinergic drugs are trihexyphenidyl (Artane®), benztropine (Cogentin®), and procyclidine hydrochloride (Kemadrin®).

Side effects associated with anticholinergic drugs include dry mouth, constipation, agitation, and painful urination (dysuria).

Botulinum toxin, or BOTOX® Cosmetic, is injected directly into muscle. BOTOX® Cosmetic blocks acetylcholine and alleviates muscle spasm for 3-6 months. Botulinum toxin may produce muscle weakness.

In some cases physicians may try to reduce spasticity or correct a developing contracture by injecting phenol into a muscle. This weakens the muscle and gives physicians and therapists a chance to stretch and lengthen the muscle with therapy, bracing, or casts. If the contracture is treated early enough, the need for surgery may be avoided.

Mechanical Aids
A variety of devices and mechanical aids can help patients with cerebral palsy overcome physical limitations. These range from simple Velcro shoe straps to motorized wheelchairs and computerized communication devices.

Computers can transform the lives of cerebral palsy patients. Fitted with a light pointer attached to a headband and a voice synthesizer, they can give a child unable to speak or write the power of communication using nothing but simple head movements.

Casting and splinting for 2-3 months can improve range of motion (ROM) of a joint and decrease muscle tone for 3-4 months.

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