Spastic Cerebral Palsy
Different parts of the body may be affected by spastic CP. During the process of diagnosing CP, your medical team will consider their evaluations, as well as their visual observations, to determine which areas of the body are being affected in the person with CP.
The following terms help identify which parts of the body are affected:
- Diplegia: Spasticity in mostly the lower half of the body.
- Hemiplegia: Spasticity mostly seen in one side of the body.
- Quadriplegia: All four limbs are affected by spasticity. Muscles of the trunk, face and mouth may also be affected.
These terms are often used inconsistently depending on the perception of the medical professional. A medical team member may describe a child’s CP as diplegia, based on his or her exam, and another may be describe it as quadriplegia.
Unilateral vs. Bilateral Cerebral Palsy
The terms bilateral (affecting both sides) and unilateral (affecting one side) have begun replacing the above terms. This is in order to more generally, and maybe more accurately, describe a persons CP. It is important to keep in mind that a description of unilateral CP is also an issue for the same reasons as the other terms. It is also important to note that the side of the body that is seen as less affected may still need to be addressed in some way.
Spastic Cerebral Palsy Treatment Options
Spasticity in CP is typically addressed by using different ways to break up, or counterbalance, the messages sent from the brain to the muscles that are causing spasticity. Oral medications, a variety of surgical procedures, and therapy programs are all different types of treatment options. More than one option may be used together to help improve the symptoms linked to spasticity.
Common treatment options, what they are, and how they are used can be found below:
- Botulinum Toxin
Botulinum toxin is a chemical made by the bacteria clostridium botulinum. In CP, it may be injected into targeted muscles to temporarily relax stiff ,or spastic, muscles by blocking the connection between a nerve and the muscle. It is thought that decreasing muscle stiffness may help the stretching of shortened muscles and it also may provide relief from pain from muscle tightness.Over the last 25 years, botulinum toxin has been commonly used to treat neuromuscular conditions, including spasticity, but it was only in 2016, the US Food and Drug Administration (FDA) gave its first approval for a brand of botulinum toxin A, called Dysport, to be used in children with CP. Dysport has been approved for the use in the treatment of lower limb muscle stiffness in cerebral palsy, and specifically a pediatric population of 2 years and older. It is very important to discuss the specific indications for use of botulinum toxin and its potential risks with your medical team.There are several formulations and strains (usually A or B used in CP) of botulinum toxin that are commonly used *”off-label” by physicians. In addition, the 2016 approval for Dysport (botulinum toxin A) was based on a study that included a specific population within CP, and with specific directions for use.
In 2009 the FDA issued a Boxed Warning for botulinum toxin (available for review on the FDA website). Discuss this warning, other potential side effects, risks and appropriate candidacy with your medical team.
- Ethanol | Ehenol Nerve Blocks
Nerve blocking using ethanol or phenol is used as a way of reducing spasticity (muscle tightness) by blocking the overactive nerve signal from the brain to a group of muscles that the nerve connects to. This is done by dissolving the myelin sheath (fatty coating) wrapped around the nerve. This approach requires more precision than the use of botulinum toxin since specific nerves are being targeted, rather than larger muscles. The effects of the injection typically wear off once the nerve regenerates which can vary widely from one person to another.Discuss potential side effects, risks and appropriate candidacy with your medical team.
- Baclofen Pump
The Baclofen pump is a refillable, programmable pump, that contains the medication Baclofen.Baclofen is used to reduce excessive muscle tone for spasticity and symptoms of dystonia.The Baclofen pump is typically implanted under the skin or muscles toward the front of the abdominal wall and it delivers the Baclofen medication via an implanted catheter that is inserted into the spine. This is called Intrathecal Baclofen. By giving the medication into the spinal canal, the medication does not circulate throughout the body first, and smaller doses of the medication are needed. This may reduce some of the side effects, or the intensity of side effects, commonly associated with taking oral Baclofen.A screening test using oral Baclofen, or a one time intrathecal dose, is usually done prior to the placement of the pump. This will help decide if the individual will respond to intrathecal Baclofen. <[>Once placed, follow-up medical care is needed approximately every three to six months to refill medication in the pump. After five to seven years, at the end of the pumps battery life, the pump is replaced.
Discuss potential side effects, risks and appropriate candidacy with your medical team.
- Selective Dorsal Rhizotomy (SDR)
SDR is a surgical procedure intended to reduce the symptoms of spastic cerebral palsy. An incision is made along the center of the lower back and once the spinal nerves are visible, the surgical team identifies the sensory rootlets causing spasticity (they test the nerves to evaluate their level of activity) and they sever the abnormal rootlets.Intensive post surgical physical therapy is required and individuals must be carefully evaluated for their candidacy. Typically people with cerebral palsy, who have multiple movement disorders, are not considered to be suitable candidates.
Discuss potential side effects, risks and appropriate candidacy with your medical team.
- Lengthening Procedures
Lengthening procedures of the muscles or tendons are surgical procedures that may be considered to reduce spasticity, address contractures, improve range of motion, and in some cases, reduce pain. There are many ways to lengthen a muscle, depending on the type and location of the muscle, and the extent to which it must be lengthened. The muscles may be detached from their connection to the bone, the tendons or tissue of the tendons may be divided or cut, or the myofascia (muscle fascia) maybe be divided. (The myofascia is a sheet of tendon-like material, mainly serving to connect a muscle with the parts it moves.) Common muscles/tendons that are lengthened include the muscles in the back of the calf, including the Achilles tendon (heel cord), the hamstring muscles/tendons behind the knee, and the adductor muscles in the groin.Lengthening of muscles and tendons are meant to improve the range of motion, but will also weaken the muscle a great deal, if to much lengthening is done.
Discuss potential side effects, risks and appropriate candidacy with your medical team.
- Tendon Transfer Procedures
In CP, not all muscles around a joint are equally affected by increased tone. It is not uncommon to find some muscles are affected by spasticity, while their opposites (antagonist muscle) on the other side of the joint are weak. Joint deformity may happen due to the over-activity of one group of muscles taking over another group. The deformity can be addressed by transferring part, or all, of the tendon of the overactive, or spastic, muscle and redirecting it and reattaching it to the other side of the joint, to balance the forces around that joint.Discuss potential side effects, risks and appropriate candidacy with your medical team.
- Medications (Oral)
Some medications you may hear about to treat spasticity include oral baclofen, diazepam (Valium), tizanidine (Zanaflex) and dantrolene (Dantrium). Gabapentin (Neurontin) is also sometimes used to treat pain associated with spasticity.With oral baclofen, patients who have had success, but end up with too many side effects, may be given information about the baclofen pump (mentioned above), which may offer the benefits of the higher doses of the medication with potentially fewer side effects. The baclofen pump has its own potential side effects and contraindications which differ from the oral medication.
Discuss potential side effects, risks, “off-label” use and appropriate candidacy with your medical team.
The information found here and more is available for download in our free cerebral palsy tool kit.
