Cerebral palsy: How a team approach benefits spasticity

two children with spasticity from cerebral palsy
PHOTO ILLUSTRATION: DAVID CHRISOM/BOSTON CHILDREN’S HOSPITAL

Cerebral palsy (CP) is an umbrella term that can refer to several different types of brain injury and that can affect many aspects of a child’s health. For these reasons, CP is best treated by a team of clinicians from multiple disciplines, who can address the full array of related concerns. In the Cerebral Palsy and Spasticity Center at Boston Children’s Hospital, patients receive care from multiple providers in one day, which makes managing care easier on families and encourages collaboration and communication between caring physicians.

“What makes our program unique is that clinicians gather together in the hallways and in clinic rooms to come up with a unique recipe for each child to make sure they are getting the best available care for their condition,” says orthopedic surgeon Benjamin Shore, MD, one of the Center’s co-directors. Here, he shares insights on the various approaches available to treat spasticity, or muscle tightness, a common symptom in children with CP.

Multiple disciplines, multiple treatment options

When patients with CP see a diverse team of specialists, they benefit from a spectrum of expertise in fields ranging from orthopedics and neurology to physical therapy and complex care. Depending on their unique situation, children and teens with spasticity related to CP may be eligible for a number of therapeutic approaches, both noninvasive and surgical. Walking is the product of a complex ballet of muscle activation and relaxation. However, in CP the interplay between muscles and joints is disrupted. Clinicians use gait analysis to help break down the motion segments in gait to help identify areas to intervene with treatment.

Medical tone management. Anti-spasticity medications (such as baclofen) or injections of Botulinum toxin may be helpful in easing muscle tightness. Clinicians can also surgically implant a baclofen pump, which can help prevent side effects by delivering the drug directly to the spinal cord and subsequent affected muscles.

Physical therapy. Either alone or in combination with orthotic devices like a brace or splint, physical therapy can be extremely beneficial in preventing muscle contractures by stretching the child’s spastic muscles. Many children receive regular physical therapy, participating in stretches, strengthening exercises and play activities that can help improve flexibility, endurance and mobility.

Occupational therapy. This approach is very helpful in giving children with CP independence, confidence and essential life skills. An occupational therapist will use exercises, games and training to help the child develop better fine motor skills, improve hand-eye coordination and master basic skills, such as getting dressed or bathing.

Orthotics. Orthotics are used to prevent deformity and to provide support or protection for the limbs and torso. These devices can include braces and splints.

Orthopedic surgery. While not always necessary, surgery may be recommended to help improve a child’s walking pattern and balance. Some children experience progressive scoliosis, which requires surgery to stabilize the spine. Surgery can also be used to help stabilize hips in the setting of progressive hip displacement.

Neurosurgery. Some children with CP have severe spasticity that affects their ability to walk. In these children, neurosurgeons may perform a selective dorsal rhizotomy, an operation that cuts certain nerves in the spine to reduce spasticity and improve a child’s movement and posture.

In general, the management of children with CP is complex and requires input from neurologists, physiatrists, orthopedic surgeons, complex care physicians and neurosurgeons, who form a virtual care team designed to deliver optimal care.

Clinicians who wish to learn more about the benefits of a multidisciplinary approach to CP can register for the continuing medical education course, “Cerebral palsy: Building a team-based approach to care,” which takes place on October 29, 2018.