Introduction

Cerebral Palsy (CP) is a lifelong neurological condition that affects movement and coordination, caused by damage to the developing brain. It is a permanent disability where the developing brain experiences irreversible damage or abnormalities which disrupt the brain’s ability to control movement and maintain posture and balance. The term “cerebral” refers to the brain and “palsy” refers to the impairment of muscle movement. Although permanent, it is a non-progressive disability thus, the symptoms do not worsen over time but may change as the child grows older.¹

CP has a frequency of about three out of 1000 live births. The majority of CP cases are due to unknown causes before birth, and a small percentage, about 6%, are due to birth complications. About 10% of cases are acquired after birth, mainly due to brain damage following bacterial meningitis, viral encephalitis, jaundice, falls, motor-car accidents or child abuse.²

All CP patients have movement and posture problems. In addition to these motor functions, other frequently accompanying dysfunctions include sensation and cognitive impairments, communication and behavioural disorders, epilepsy, and malnutrition. Symptoms and severity of each symptom vary greatly among patients, depending on which part of the brain was injured. The risk of mortality also increases proportionally with increasing number of impairments. 

Currently, there is no cure available for CP. Still, supportive treatments like physical and occupational therapy, and medications are available to improve patients’ functionality and capabilities for the best possible quality of life.³

Physical therapy

Physical therapy or physiotherapy is the keystone in CP treatment – it focuses on movement, mobility, and function. Exercises like stretching, resistive, or strength training activities are tailored individually depending on the symptoms presented. These exercises can improve muscle strength, balance, and motor skills. Patients are advised to do these exercises regularly to encourage movement of the muscles, strengthening the muscles to prevent the muscles from becoming weak.^4,5

Resistance exercise is an effective technique to enhance muscle strength – exercising a muscle against external resistance. Resistance exercise should be started gradually under the supervision of physiotherapists. It begins with a “familiarisation” period with minimal intensity activity, usually single-joint exercises for at least two to four weeks to allow the body muscles to slowly get into the rhythm.

Patients can then move onto multijoint exercises for the following weeks, for at least twelve weeks to see an improvement in muscle strength. Examples of resistance exercises are push-ups or squats (multijoint), or with the use of equipment like bands and dumbbells (single-joint). 

The more resistance there is, the harder the muscles have to work. The muscles will have to adapt to the external force and gradually increase in strength. It is important to maintain resistance exercises to maintain the achieved muscle adaptations – as soon as the exercises are stopped, the muscle strength obtained from these exercises is lost.⁶

Besides improving muscle strength, regular stretching is required to relieve the tightness in spastic muscles – the muscles are tight and stiff hence, it is difficult to move and the range of movement is reduced. Passive stretching helps to increase the range of movements, and reduce the stiffness and tightness of muscles, thus improving walking efficiency, and preventing muscle contracture.

It is typically performed once to twice daily and can be done at home fairly easily upon demonstration by physiotherapists. Physiotherapists may also incorporate the use of splinting and casting to maintain the passive stretch and normal range of motion. However, in CP, the casts and splints do not need to be worn at all times and a resting period is allowed to avoid complications.^7,8

Occupational therapy

While physical therapy focuses on mobility, occupational therapy focuses on fine and gross motor skills to enable patients to perform daily tasks more easily. Occupational therapists help to maximise the patient’s ability to safely perform daily tasks and promote independence and productivity, either at school, at home or in the community. Each occupational therapy is tailored individually, depending on the patient’s specific needs. 

Occupational therapists are involved in some of these activities: 

• Teaching patients or caregivers how to handle basic activities like getting dressed, eating and bathing
• Assist in tasks requiring fine motor skills such as writing, typing, twisting a doorknob 
• Train the patients about the safest way to get into and out of bed or chairs
• Provide advice on getting a job or returning to work
• Teach patients how to use assistive devices such as wheelchairs
• Educate caregivers on how to effectively support a patient with CP

Some occupational therapists use a sensory integration approach in children with sensory processing difficulties, which restricts their participation in daily life activities. Sensory integration refers to the processes in the brain whereby our senses send signals to the brain, and we process the signals and respond appropriately. These senses include vision, auditory, smell, taste, touch, and movement. 

CP patients have difficulty processing these signals thus, are unable to react accordingly, which hinders their learning and behaviour. This approach follows a set of principles that addresses the underlying dysfunctions. It requires the therapists to have exceptional observation skills to understand the patient’s behaviour and interests and create a sensory-rich activity or environment that allows the patient to pursue achievable challenges.⁹

Medications

The use of medications in CP is mainly to relieve symptoms. Some common medications used to relieve the main symptoms of muscle stiffness and tightness are:

• Botulinum toxin (Botox), is injected intramuscularly to relax contracted muscles, hence reducing muscle spasticity. By reducing spasticity, patients can have an increased range of motion, resulting in a better quality of life. The toxin works by preventing the nerve cells from over-activating the muscles, and each dose of injection usually lasts for about three months. In addition, it also assists in posture correction as the muscles are less stiff, and reduces any pain and discomfort related to muscle tension. Botox is prescribed for children with CP from the age of 2 years^10,11
• Oral medications such as baclofen, diazepam, and dantrolene – are short-acting muscle relaxants and often come with many side effects like sedation, dizziness, confusion, lethargy, nausea, lowered seizure threshold, central nervous system depression, and more. As these side effects can be detrimental to some CP patients, they are used only when necessary and continuous monitoring is required¹²
• Intrathecal baclofen therapy (ITB) – is the injection of baclofen (muscle relaxant) directly into the fluid of the spinal cord via an implantable pump. Since the dose needed to provide a therapeutic effect is lower, the side effects from the medication are also reduced
  • Furthermore, the pump allows CP patients to adjust the dosage accordingly if the symptoms worsen at certain times of the day or night. As this is a direct-targeted therapy, it is usually used in chronic CP patients with uncontrolled muscle movement throughout the body and severe stiffness
  • The continuous use of ITB does not only improve motor control and function, but it also provides substantial pain relief, improves sleep, promotes independence, and facilitates ease of care
  • However, it can be very costly as it requires refills and patients or caregivers should ensure the injections are not stopped abruptly as it could cause serious withdrawal complications like seizures and multi-organ failure. Compared to the other treatment options, ITB also comes with a risk of infection and surgical complications^13,14
• Anti-epileptic drugs are some other medications to relieve non-muscle-related symptoms. Many children with CP also have epilepsy. Anti-epileptic drugs are started almost immediately after the first seizure episode, as seizures are likely to recur. The course of epilepsy and its treatment depends on the type and severity of CP
• The ketogenic diet – a diet with low carbohydrate, high fat and moderate protein, is also recommended for CP patients with epilepsy, although they should consult with a dietician to prevent malnutrition as there is also a high rate of malnutrition in CP patients^15,16 
• There is a distinct reduction in bone density especially with CP patients who are unable to walk and often stay indoors, which puts them at high risk of osteopenia and osteoporosis. These patients have weaker bones and are likely to fracture their bones. Medications or supplements such as calcium, vitamin D and bisphosphonates help to improve bone density and reduce the risk of fracture^17,18

Summary

Cerebral palsy is a medical condition that cannot be cured. However, various therapeutic interventions with interdisciplinary approaches are available to manage CP. Healthcare professionals often use a combination of physical and occupational therapy, medications, and occasionally surgical and technical procedures, to treat CP patients. 

The treatments are often individualised based on the patient’s needs, with regular evaluations and progress assessments. As CP is commonly diagnosed in children, early intervention is essential to prevent secondary impairments and to improve patients’ developmental capabilities.