Cerebral Palsy and Spasticity
What is spastic cerebral palsy?
Cerebral palsy (CP) is a neurological disorder that affects movement, muscle tone or posture and is caused by damage to the motor control centers of the developing brain. It can occur during pregnancy, during childbirth or after birth up to about the age of 3 years. CP affects approximately one in 500 live births, and spastic cerebral palsy is the most common type.
Spasticity is an abnormal imbalance between excitatory and inhibitory neurotransmitters which send signals to muscles. This imbalance results in increased muscle rigidity and tone, especially in the legs of a child with spastic diplegia, or on one entire side of the body in a child with spastic hemiplegia.
Spastic diplegia involves muscle stiffness predominantly in the legs and less severely in the arms and face, although the hands may be clumsy. Toes point up when the bottom of the foot is stimulated. Tightness in certain leg muscles can make the legs move like scissors. Children with spastic diplegia may require a walker or leg braces. Intellect and language skills are usually normal.
Spastic hemiplegia affects the arm, hand and leg on one side of the body. Children with spastic hemiplegia generally walk later in development and on their tiptoes because of tight heel tendons. The arm and leg of the affected side are frequently shorter and thinner.
The natural history of spastic diplegia or spastic hemiplegia without treatment is progressively poor quality of life because these children cannot walk. They are at risk for pressure ulcers from prolonged sitting and often suffer from emotional and psychiatric problems because of their inability to move.
The cause of spastic cerebral palsy is unknown, but spastic diplegia has been associated with prematurity, low birth weight and periventricular leukomalacia, a disease that is caused by a lack of oxygen or blood flow to the periventricular area (white matter) of the brain.
Watch Dr. Manish Shah’s online presentation on Spastic Cerebral Palsy to learn more about symptoms, diagnosis and the latest treatment options available for this condition at Children's Memorial Hermann Hospital.
How is spastic cerebral palsy diagnosed?
Children with spastic cerebral palsy often walk on their tiptoes and have trouble relaxing the muscles of their legs to have a normal gait. A pediatrician or neurologist can evaluate your child for increased rigidity and tone of the lower extremities. Your physician may order an MRI of the brain which may show periventricular leukomalacia.
How is spastic cerebral palsy treated?
Even though CP cannot be cured, treatment often improves a child’s capabilities. Many children go on to enjoy near-normal adult lives if their condition is properly managed. Physical therapy, occupational therapy, therapeutic recreation, and speech and language therapy provide significant benefits. The earlier treatment begins, the better the chance a child has of overcoming developmental disabilities or learning new ways to accomplish challenging tasks.
For many children with CP, therapy and routine stretching exercises can make a significant difference in their muscle stiffness and frequency of involuntary movements. Physicians may prescribe medication in conjunction with physical therapy to help facilitate the child’s progress. Oral baclofen is an example of a medication that may be prescribed to improve hyperactive reflexes and ease excessive muscle tone. Once absorbed into the bloodstream, baclofen relaxes the muscles and reduces spasms, cramping, and stiffness, allowing for more successful physical therapy outcomes.
When the child’s spasticity affects a few, specific muscle groups, Botox® (onabotulinum toxin) may be injected locally. This procedure allows the toxin to relax the nerve endings in the affected muscle group, reducing the frequency of involuntary muscle contractions and improving range of motion in the joints that the injected muscles control.
For more severe cases, surgical procedures such as selective dorsal rhizotomy (SDR) or the placement of an intrathecal baclofen pump (ITB) are recommended when more conservative treatments – physical therapy and oral or injectable medications – have failed to reduce spasticity.
During SDR, a neurosurgeon locates and selectively severs overactivated nerves at the base of the spinal column. The procedure is most commonly used to relax muscles and decrease chronic rigidity in one or both of the lower extremities. Benefits of SDR include immediate reduction of spasticity in patients ages 2 to 40 with spastic diplegia or spastic hemiplegia and reduced risk of spinal deformities in later years. Potential side effects include sensory loss, numbness, or uncomfortable sensations in limb areas once supplied by the severed dorsal nerve rootlets. A large surgical case series (approximately 2,700 cases) showed a minimal risk of a cerebrospinal fluid leak or need for surgical fusion.
Another surgical option is an intrathecal baclofen pump. The pump uses a small catheter to deliver a concentrated form of baclofen directly to the intrathecal space surrounding the spinal cord, where the medication mixes with the cerebrospinal fluid and circulates throughout the central nervous system. Because the medication is administered continuously and directly into the intrathecal space, an ITB can be effective in providing a steady relief of symptoms without the drowsiness that is normally associated with oral baclofen. Potential side effects include increased weakness, cerebrospinal fluid leaks, and the risk of infection around the device, which is implanted below the skin in the abdomen. The pump does require regular maintenance by a physician, and because it is battery powered, the pump will need to be replaced every 5 to 7 years.
At the Texas Comprehensive Spasticity Center, our affiliated physicians collaborate to provide personalized care for each patient, choosing the best treatment for each individual. The comprehensive team consists of a pediatric neurologist who specializes in movement disorders, pediatric neurosurgeons, pediatric orthopedic surgeons, and pediatric physical medicine and rehabilitation physicians. Surgeons and physicians at TCSC treat patients alongside physical and occupational therapists, a clinical research coordinator, physician assistants, medical assistants, and a dedicated program coordinator. This multidisciplinary approach ensures the most comprehensive specialized treatment for each patient, beginning with evaluation – observation, videos, and medical tests – and continuing through treatment and therapy. To learn more about the Texas Comprehensive Spasticity Center, click here »
Aubree was diagnosed as a baby with spastic triplegic cerebral palsy. In her case, both her legs and her left arm had spasticity – a condition that made her affected limbs rigid and stiff. Because of the spasticity, Aubree has had physical therapy since she was a baby to help manage it. She has needed assistance to help with her mobility and has used a pediatric walker since she was 4. “Walking on my own has always been my goal,” Aubree says. “Now, because I don’t have the spasticity, I have a much greater chance of that happening.”
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Born seven weeks early, Darius suffered an intraventricular hemorrhage in the first few days of life – a common occurrence with premature birth. The hemorrhage left him with a single significant deficit: spasticity in the lower limbs.
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For additional information on spastic cerebral palsy, visit the Centers for Disease Control and Prevention page here or the National Institute of Neurological Disorders and Stroke page here »
This information, although based on a thorough knowledge and careful review of current medical literature, is the opinion of doctors at McGovern Medical School at UTHealth and is presented to inform you about spastic cerebral palsy. It is not meant to contradict any information you may receive from your personal physician and should not be used to make decisions about treatment. If you have any questions about the information above or your child's care, please contact a doctor affiliated with Children’s Memorial Hermann Hospital.