Cerebral Palsy (CP)
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.
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.
Orthopaedic surgery can prevent spinal deformities and contractures but requires particular expertise and appropriate rehabilitation following surgery.
When contractures cause severe movement problems, surgery to lengthen muscles and tendons may be recommended. Gait analysis is used to identify problem muscles, eliminate compensation factors associated with walking, and check surgical results. Cameras and computers record and analyze the patient’s walk, and electromyography records muscle activity.
Surgically lengthening a muscle makes it weaker and may require months of recovery. Whenever possible, therefore, doctors try to fix affected muscles with a single surgery. If more than one procedure is required, operations usually are scheduled as close together as possible.
Dorsal root rhizotomy treats spasticity in the legs by selectively severing nerves that overstimulate leg muscles. The procedure is controversial, but it can benefit some CP patients, particularly those with spastic diplegia.
Stereotactic neurosurgery may improve rigidity, choreoathetosis, and tremor. The area of the brain treated controls the part of the body meant to be improved. A head CT scan is performed to produce images of the brain. Coordinates of the location to be treated are moved to a stereotactic frame. The frame is used like a map to guide an electrode to the target area in the brain. An electrical impulse is sent through the electrode and into the brain tissue to change the brain cells.
Stereotaxic thalamotomy can reduce some hemiparetic tremors. This procedure involves cutting parts of the thalamus, the brain’s center for relaying messages from the muscles and sensory organs. There is significant risk with this procedure.
Chronic cerebellar stimulation is an experimental technique that uses electrodes surgically implanted on the surface of the cerebellum – the part of the brain that coordinates movement – to decrease spasticity and improve motor function by stimulating certain nerves. Some studies claim the procedure improves spasticity, while others report less satisfactory results.
Incontinence, caused by faulty control over the bladder muscles, can be treated with exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices that replace or aid muscles.
Drooling, caused by poor functioning of the muscles of the throat, mouth, and tongue, can be difficult to control. Anticholinergic drugs reduce the flow of saliva but may produce side effects like mouth dryness and poor digestion. Surgery sometimes helps, but also can worsen swallowing problems. Biofeedback has been proven helpful in patients who are intellectually unimpaired and motivated.
Eating and swallowing problems may require the caregiver to prepare food in a semisolid fashion, such as strained vegetables and fruits. Physical therapy can support and promote proper positioning while eating or drinking, or help extend the neck away from the body to reduce the risk of choking.
Severe swallowing problems may necessitate the use of a tube to deliver food down the throat and into the stomach. Gastrostomy, which involves making a surgical opening in the abdomen that allows tube-feeding directly into the stomach, is sometimes necessary.