A multidisciplinary team of healthcare professionals develops an individualized treatment plan based on the specific needs of each patient. The individuals with cerebral palsy (CP), families, teachers, and caregivers should be involved in all phases of planning, decision making, and treatment.
Healthcare providers for children with CP usually include a pediatrician, pediatric neurologist, or pediatric physiatrist (doctor who specializes in physical medicine). A family doctor, neurologist, or physiatrist provides primary care for adults with CP.
Other specialists on the team may include orthopedist or orthopedic surgeon (to predict, diagnose, and treat associated muscle, tendon, and bone problems), a 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), and a psychologist (to help address negative or destructive behaviors and guide the patient and the family through the stresses and demands presented by cerebral palsy).
The need for and types of therapy may also 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 a diagnosis of CP is made. A physical therapist specializes in improving the development of the large muscles of the body, such as those in the legs, arms, and abdomen (called gross motor skills). Physical therapists help children with CP learn better ways to move and balance. They may help children with CP learn to walk, use a wheelchair, stand by themselves, or go up and down stairs safely. Physical therapists will also work on skills such as running, kicking and throwing, or learning to ride a bike. Physical therapy usually begins in the first few years of life, or soon after the diagnosis of cerebral palsy is made. These therapists use specific sets of exercises to work toward the prevention of musculoskeletal complications. An example of this is preventing the weakening or deterioration of muscles that can develop with lack of use. Also, physical therapy will help avoid contractures, in which muscles become fixed in a rigid, abnormal position. Physical therapy will help prevent musculoskeletal problems, as well as help the child perform common everyday activities.
Occupational therapy: An occupational therapist specializes in improving the development of the small muscles of the body, such as the hands, feet, face, fingers and toes. These therapists also teach daily living skills, such as dressing and eating, as well as make sure children are properly positioned in wheelchairs. They may teach the child better or easier ways to write, draw, cut with scissors, brush their teeth, dress, and feed themselves. Occupational therapists will also help the child find the right special equipment to make everyday life a little easier.
Speech and language therapist: A speech and language therapist helps develop better control of the jaw and mouth muscles, which can improve speech and language skills and eating abilities. They also help develop creative communication methods for those who can not speak. A speech and language therapist will work with the child on communication skills. This means talking, using sign language, or using a communication aid. Children who are able to talk may work with a speech therapist on making their speech clearer, or on building their language skills by learning new words, learning to speak in sentences, or improving their listening skills. Children who can not talk may learn sign language or how to use special equipment, such as a computer that actually talks for the individual.
Surgery: Surgery is not always necessary for children with CP, but it is sometimes recommended to improve muscle development, correct contractures, and reduce spasticity in the legs. Before selecting any surgical procedure, the doctor will thoroughly discusses the risks involved, long-term effects, and postoperative follow-up. Second opinions are generally recommended and speaking with other parents whose children have had the same surgical procedure may be helpful.
Children with cerebral palsy often walk on their toes. This may indicate a tight heel cord. When other treatments for this fail, such as splints and braces, surgery may help correct it by lengthening the tendon. This surgery may help improve the child's ability to walk, improve balance, and prevent further deformity. Surgery is also available to relieve spasticity in the legs and hips of children. This surgery involves identifying sensory nerve fibers behind the spinal cord and then selectively cutting those nerve fibers thereby reducing spasticity. Research on this surgery is still being conducted. The adductors are muscle groups that bring the legs together. If a child's doctor determines that the adductors are causing deformities or problems with walking, they may suggest a surgical procedure to cut the tendon, which can release muscle contractures and improve mobility.
Drug therapy: Doctors may prescribe drugs to prevent or control seizures associated with CP such as carbamazepine (Tegretol®), phenytoin (Dilantin®), and valproic acid (Depakene® or Depakote®). Drug therapy can also help reduce spasticity associated with cerebral palsy and may include the use of diazepam (Valium®, a benzodiazepine), baclofen (Liorisal®, a muscle relaxant), and dantrolene (Dantrium®, a muscle relaxant). If surgery is not recommended, these drugs can help reduce spasticity for short periods. However, their long term value is still being researched. Side effects include drowsiness and fatigue (excessive tiredness). Although drug therapy may not completely correct complications associated with cerebral palsy, evidence does show that it helps manage problems such as seizures and spasticity. Anticholinergic drugs 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®) and benztropine (Cogentin®). Side effects associated with anticholinergic drugs include dry mouth, constipation, agitation, and dysuria (painful urination).
Botulinum toxin, or BOTOX®, is injected directly into muscle. BOTOX® blocks acetylcholine and alleviates muscle spasm for three to six 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.
Sensory integration therapy: Another approach to help children with CP achieve their optimal level of functioning is sensory integration therapy (SIT). SIT helps to overcome problems experienced by many young children in absorbing and processing sensory information. Encouraging these abilities ultimately improves balance and steady movement. Therapies include stimulating touch sensations and pressures on different parts of the body.
Adaptive equipment: Special equipment is also available for children with CP. Wheelchairs, walkers, and braces may help children with CP to perform daily tasks.
A wheelchair is sometimes used when a child cannot walk. This will allow the child to move from one place to another. Many children with cerebral palsy can use their arms to roll the wheels of their wheelchair themselves and can move around without much difficulty at all. There are also wheelchairs available that are motorized. This type of wheelchair has a motor that moves the wheels for the child. There may be a joystick on one arm rest that the child can operate on his or her own.
A walker is a piece of equipment usually made out of light metal. It most often will have four legs that are adjustable in height. Some children with cerebral palsy can walk, but have poor balance and may fall. They may use a walker to help them balance and get around without the use of a wheelchair.
Because of the fine motor problems often associated with cerebral palsy, children may have a hard time using utensils for eating. Special handles or grips are available for children who have trouble holding onto small objects, such as a fork or spoon. Eating utensils that are specially designed for children with fine motor problems also exist. They may be curved or bent and are usually designed to fit the child's needs. Special grips and handles are also used on pencils and pens to make them easier for the child to hold and use.
Communication aids, including computers, books, posters, and alphabet boards, are available for children who are hard to understand or who have difficulty talking with others.
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. Medications for psychiatric symptoms may also be used, including antidepressants (such as fluoxetine or Prozac® and sertraline or Zoloft®) and antipsychotic medications (such as quetiapine or Seroquel®).
Support Groups: To meet the challenges of cerebral palsy, patients, families, and caregivers need help and support. There are many government-supported and private volunteer groups that provide information about prevention, diagnosis, and treatment, as well as clinical and support services.
The integrative therapies listed below have been reported useful in movement disorders in general. Although the use of these therapies has not been studied in cerebral palsy, the use in movement disorders suggests their use in cerebral palsy may improve symptoms associated with the condition.
Good scientific evidence
5-HTP: Cerebral ataxia results from the failure of part of the brain to regulate body posture and limb movements. 5-HTP has been observed to have benefits in some people who have difficulty standing or walking because of cerebral ataxia. Some research shows that 5-HTP may allow individuals with unsteady movements to stand alone without assistance, walk without aid, or improve coordination. Other research shows no benefit. Further research is needed before a conclusion can be drawn. 5-HTP may interact with other mood altering medications such as antidepressants and anti-anxiety drugs.
Music therapy: Music therapy has been reported to improve symptoms in people with Parkinson's disease. Modest improvement were seen in symptoms including motor coordination, speech intelligibility and vocal intensity, bradykinesia (slow movement), emotional functions, activities of daily living, and quality of life.
Omega-3 fatty acids: Omega-3 fatty acids are essential fatty acids found in cold water fish (including salmon, herring, and tuna) and other marine life (such as krill and algae). Omega-3 fatty acids can also be found in certain plants and nuts, including purslane and walnuts. An investigational drug for the symptomatic treatment of the neurological condition Huntington's disease (HD) is ethyl-EPA (Miraxion®), a pharmaceutical drug based on a component of omega-3 fatty acids called eicosapentaenoic acid (EPA). Miraxion® seems to help decrease the chorea (involuntary movements) that can be debilitating in individuals with HD. Omega-3 fatty acid supplements (including fish oils) may cause an increase in bleeding in sensitive individuals, including those taking blood thinning drugs such as warfarin (Coumadin®) or those with bleeding disorders. More research should be performed for the use of Miraxion® in other neurological disorders.
Unclear or conflicting scientific evidence
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique involves finger pressure at acupoints and along body meridians (energy lines). It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. Preliminary clinical evidence from one small study with individuals with facial spasm reports improvement when using Shiatsu acupressure. Further research is needed.
Acupuncture: Acupuncture has been reported to help relieve symptoms of some neurological disorders including cerebral palsy, hemiplegia (full or partial paralysis of one side of the body due to disease, trauma, or stroke), Parkinson's disease (characterized by fine muscle coordination and tremors), spinal cord injury, Tourette's syndrome (characterized by "tics"), and trigeminal neuralgia. One study found that parents were impressed with acupuncture therapy on functional well-being in Huntington's disease in children. There is insufficient evidence available from well-designed studies for using acupuncture in neurological disorders such as Tourette's syndrome. More trials need to be performed.
Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Preliminary research suggests that Alexander technique instruction may improve fine and gross movements and reduce depression in patients with Parkinson's disease. Well-designed human trials are necessary.
Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Adrenoleukodystrophy (ALD) is a rare inherited metabolic disorder characterized by the loss of fatty coverings (myelin sheaths) on nerve fibers in the brain and progressive destruction of the adrenal gland. ALD is inherited as an x-linked genetic trait that results in dementia and adrenal failure. Injections of arginine have been proposed to help manage this disorder, although most study results are inconclusive. Further research is needed to evaluate the use of arginine in ALD and other neurological conditions.
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system) and how this relationship affects the preservation and restoration of health. Although there is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of Parkinson's disease, anecdotal reports suggest a positive impact on fine muscle coordination in some individuals. More clinical research is necessary.
Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. There is promising evidence from one case control study and two case series to support the use of CoQ10 in the treatment of symptoms associated with the neurological condition Friedrich's ataxia. These studies are lacking in sample sizes. A future randomized controlled trial with a substantial number of participants is necessary for proper evaluation of efficacy of CoQ10 in Friedrich's ataxia. Further research using CoQ10 for neurological conditions is necessary.
Ginseng: A clinical study found that patients with neurological disorders may improve when taking Asian ginseng (Panax ginseng). This supports research findings that report that Panax ginseng improves cognitive function. However, more research is needed in this area.
L-carnitine: Although used traditionally for support of neurological conditions, one poorly designed preliminary clinical study reported that L-acetyl-carnitine (carnitine or L-carnitine) possesses neither efficacy nor toxicity towards patients with Huntington disease. Further trials are required to determine if L-carnitine is beneficial in individuals with neurological disorders.
Melatonin: Melatonin is a naturally occurring hormone that helps regulate the sleep/wake cycles (circadian rhythm). Melatonin has been reported useful in neurological conditions including Parkinson's disease, periodic limb movement disorder, and tardive dyskinesia. The use of melatonin in these conditions, however, is not supported by rigorous scientific testing. Better-designed research is needed to determine if melatonin is beneficial in individuals with neurological disorders.
Moxibustion: Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi (energy). One small study reported treatment of trigeminal neuralgia with cupping to have a significant therapeutic effect. However, there is insufficient available evidence and more clinical studies are needed in this area
Reiki: Reiki is a system of lying on of the hands that originated in as a Buddhist practice approximately 2,500 years ago. One randomized trial suggests that Reiki may have an effect on autonomic nervous system functions such as heart rate, blood pressure, or breathing activity, important in neurological disorders that may damage autonomic function. Large, well-designed studies are needed before conclusions can be drawn.
Safflower: Friedreich's ataxia is a genetic neurodegenerative disease. In one clinical trial, safflower (Carthamus tinctoria) decreased deterioration caused by Friedreich's ataxia. More high-quality studies with larger sample sizes are needed to establish safflower's effect on neurological conditions.
Taurine: Taurine may affect cellular hyperexcitability by increasing membrane conductivity to potassium and chloride ions, possibly by altering intracellular (within the cell) availability of calcium. Results from a single non-randomized trial suggest that taurine supplementation may result in improvements in myotonic (slow relaxation after contraction of muscles) complaints. Well designed clinical trials are needed.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. Several studies have reported benefits of TENS therapy in patients with trigyminal neuralgia (facial pain). However, these trials have been small without clear descriptions of design or results. A small clinical study also found TENS effective in decreasing symptoms associated with spinal cord injury. Therefore, additional research is needed before a firm conclusion can be drawn in the area of neurological disorders.
Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine and for myelin formation. Pyridoxine deficiency in adults principally affects the peripheral nerves, skin, mucous membranes, and the blood cell system. In children, the central nervous system (CNS) is also affected. Major sources of vitamin B6 include: cereal grains, legumes, vegetables (carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. Some prescription drugs called neuroleptics, which are used in psychiatric conditions, may cause movement disorders as an unwanted side effect. Vitamin B6 has been studied for the treatment of acute neuroleptic-induced akathisia (NIA, a neuromuscular disorder characterized by a feeling of "inner restlessness" or a constant urge to be moving) in schizophrenic and schizoaffective disorder patients. Preliminary results indicate that high doses of vitamin B6 may be useful additions to the available treatments for NIA, perhaps due to its combined effects on various neurotransmitter systems. Further research is needed to confirm these results.
Vitamin E: Vitamin E has been studied in the management of tardive dyskinesia, and has been reported to significantly improve abnormal involuntary movements, although the results of existing studies are not conclusive enough to form a clear recommendation. Vitamin E may be more effective in higher doses and in people who have had tardive dyskinesia for less than five years.
Other supplements used in movement disorders that have unclear or conflicting scientific evidence include ashwagandha root (Withania somniferum), dehydroepiandosterone (DHEA), dong quai root (Angelica sinensis), homeopathic dilutions of belladonna (Belladonna atropa), choline, psychotherapy, selenium, and yohimbe bark (Pausinystalia yohimbe).
Historical or theoretical uses lacking sufficient evidence
Integrative therapies used in movement disorders, such as cerebral palsy, that have historical or theoretical uses but lack sufficient clinical evidence include: aloe (Aloe vera), arabinoxylan, aromatherapy, art therapy, asparagus (Asparagus officinalis), arnica (Arnica montana), bacopa (Bacopa monnieri), bitter orange (Citrus aurantium), black cohosh (Actaea racemosa), cat's claw (Uncaria tomentosa), chelation therapy (EDTA), chondroitin sulfate, cordyceps (Cordyceps sinensis), devil's claw (Harpagophytum procumbens), horse chestnut (Aesculus hippocastanatum), kava kava (Piper methysticum), kudzu (Pueraria lobota), hypnosis, magnet therapy, lycopene, massage, muira puama (Ptychopetalum olacoides), omega-3 fatty acids, prayer, qi gong, relaxation, St. John's wort (Hypericum perforatum), and valerian (Valeriana sp.).
Adequate prenatal care during pregnancy, labor, delivery, and immediately after the delivery of the infant is essential. Healthcare professionals recommend that individuals see their doctor regularly, take prenatal vitamins as prescribed, stop smoking, and eat healthy foods including more fresh fruits and vegetables. Failure to perform the necessary tests and accurately interpret the results of these tests may cause injury to the developing brain. Improper use of medications, unrecognized fetal distress, untreated infections, excessive use of abortion, and the failure to perform a timely cesarean section may result in damage to the motor centers in the brain.
injuries by using child safety seats in automobiles and helmets when riding bicycles and skateboards is important. Supervision of young children closely during bathing and swimming helps prevent injury.
Vaccination against German measles (rubella) is recommended before becoming pregnant.
Physical exhaustion from inadequate rest or recovery from illness or injury can lead to an overall decline in physical and mental function. Ways to maintain physical function include appropriate wheelchair seating and posture, assumption of various positions out of the wheelchair, and use of a wheelchair when fatigued and when walking is difficult. Also, regular and appropriate exercise, including stretching exercises and exercises to maintain flexibility in joints, is recommended.
Maintaining ideal weight is important. It may be best to avoid refined foods such as white breads, pastas, and sugar. Doughnuts, pastries, bread, candy, soft drinks, and foods with high sugar content may all contribute to weight gain that may worsen symptoms of movement disorders.
Food can be cut into small pieces, softened, or pureed to ease swallowing and prevent choking. While some foods may require the addition of thickeners, other foods may need to be thinned. Dairy products, in particular, tend to increase the secretion of mucus, which in turn increases the risk of choking.