What is spasticity?
The majority of children with cerebral palsy develop spasticity, in which their muscles tighten involuntarily, causing stiffness. Spastic cerebral palsy is often classified by the areas of the body that are affected. The three most common subtypes of spastic cerebral palsy are as follows:
- Hemiplegia — one side of the body is involved (usually the upper and lower extremity on the involved side)
- Diplegia — the lower extremities are more involved than the upper extremities
- Quadriplegia — all four extremities are equally involved
Spasticity inhibits normal muscular movement and function and can result in delayed or impaired motor development. Some children with spasticity may also experience difficulty with posture and positioning. Over time, spasticity can lead to contractures, joint deformity, scoliosis, and other secondary impairments.
In children with cerebral palsy, spasticity is caused by impaired control of the muscles by the brain.
Spasticity management includes a variety of treatment options including stretching, splinting and bracing, chemoneurolysis via botulinum toxin A (brand name Botox®) and/or phenol injections, antispasticity medications, intrathecal baclofen (ITB) therapy, and selective dorsal rhizotomy (a type of surgery).
Bracing is a first line option for children with gait abnormalities resulting from spasticity. Spastic muscles are inherently weak, so flexible deformities can be managed with braces in order to augment function.
Chemoneurolysis is achieved by the injection of medication into select muscles. This results in targeted spasticity management to the areas where the child needs it most. At CHOP, both Botulinum Toxin A (sold under the commercial name Botox) and phenol are used for chemoneurolysis procedures. These drugs can temporarily reduce spasticity (with the effect typically lasting four to six months), and may delay the need for surgery.
Antispasticity medications can be given either orally or via feeding tube. Medications treat generalized spasticity, as they will affect all the muscles of the body. The antispasticity medications most frequently prescribed by our physicians include Baclofen, Diazepam, and Tizanidine.
We will evaluate your child’s needs to determine which medication and dose we think will work best and will stay in touch with you to titrate the medication to the optimal dose for your child.
Intrathecal baclofen (ITB) therapy requires a surgical implantation of a medication pump into the patient’s abdomen, and the pump then delivers medication directly to the intrathecal space (fluid surrounding the brain and spinal cord) via a flexible catheter.
The pump placement surgery is performed by the neurosurgery group at CHOP, and medication dosing and pump management is done by Physical Medicine and Rehabilitation. This treatment is generally considered for patients with more severe spasticity and muscle tone.
Spastic muscles do not grow normally, and over time, permanent muscle contracture (tightening) and deformity can develop.
In children with diplegic cerebral palsy, contractures worsen around the ages of 4 to 5, and the child's ability to walk either does not improve or deteriorates. These contractures can lead to hip displacement or dislocation, gait abnormalities, or neuromuscular scoliosis.
When contractures occur, orthopaedic surgery is often the best intervention to address them. Common types of orthopaedic surgery are as follows:
Muscle lengthening procedures may be performed surgically to improve joint motion and gait (walking), and to prevent deformities. Lengthening procedures can also be used to decrease the need for bony surgery in younger children, and their effects last longer than those of botulinum toxin.
Tendon transfers allow muscles to partially be transferred physically to a different location, which can balance the forces across a joint in a more advantageous fashion.
Bony reconstruction allows for direct restoration of anatomic position of joints (in the case of neuromuscular hip dislocation/dysplasia), or relief of rotational abnormalities which result in brace intolerance.
In cases where the deformity is too severe to be managed with simple realignment, fusion can provide a durable option to provide long term support of a patient's skeleton.
Physical therapy is beneficial at an early age when children have cerebral palsy. It is also key after surgical procedures. Our expert rehabilitation staff will work with your child to design therapy for his or her individual needs.
After surgery on most walking children, only below-knee casts are used. Therapy to promote maximum joint motion, muscle strengthening and a return to walking can begin in the days immediately after the procedure.
Neurosurgery is another option to treat spasticity in children with cerebral palsy. Selective dorsal rhizotomy (SDR) is a surgery that reduces the tone and spasticity of the legs to a greater degree than other treatments. In SDR, neurosurgeons aim to reduce the spasticity of your child's legs by cutting a portion of the dorsal roots of spinal nerves as they leave the spinal column.
Working closely with Children's Hospital of Philadelphia's pediatric neurosurgeons, we can assess to see if your child is a candidate for this surgery.
Reviewed by Maureen Sullivan, MSW, MBA, Keith D. Baldwin, MD, MPH, MSPT, Benjamin C. Kennedy, MD, Shih-Shan Lang Chen, MD