Assessing a child for cerebral palsy treatment and therapy starts with understanding the etiology, which parts of the body are affected and identifying the predominant movement pattern, according to Catherine P. Schuster, M.D., medical director of Norton Children’s Physical Medicine & Rehabilitation, affiliated with the UofL School of Medicine.
“The underlying cause of cerebral palsy can help guide what I think I’m going to see during assessment, while the affected body parts and movement patterns will inform the treatment strategies,” said Dr. Shuster, who is also an associate professor of medicine at the University of Louisville School of Medicine.
There are a number of five-point scales that also help define the extent and severity of cerebral palsy.
“As a rehab physician, what I want to do is optimize function and quality of life. By addressing these different functional scales, we are able to do our best job to promote the unique needs of our patient,” Dr. Shuster said during a recent continuing medical education opportunity.
- GMFCS – Gross motor function classification system
- MACS – Manual ability classification system
- CFCS – Communication function classification system
- EDACS – Eating and drinking ability classification system
- VFCS – Visual function classification system
A 1 on each scale signifies the child is minimally affected, while a 5 denotes complete dependence for the particular skill set. A child who scores a five on all the scales would be dependent for all mobility using a manual chair, limited or no head control, no functional ability to manipulate objects, no reliable means of communication, unable to eat or drink safely and no means of visual recognition, even with adaptations.
With all those systems potentially affected, cerebral palsy patients benefit from a multidisciplinary approach that could pull in the skills of some or all of the following specialties.
- Developmental pediatrician or complex care pediatrician
- Neurologist
- Neurosurgeon
- Nutritionist
- Orthopedic surgeon
- Orthotist
- Physiatrist
- Physical therapist, occupational therapist, speech language pathologist
- Psychologist
- Pulmonologist
- Social worker
Physical therapy can be delivered as inpatient for intensive treatment, but also at home via video conference, outpatient and acute-care hospital therapies. Each patient’s needs and circumstances influence where they get therapy, what kind of therapy and how often.
Before using bracing, Dr. Schuster advises considering what you want the bracing to achieve: function, positioning, static stretch? And when do you want the child to wear it?
“It’s very easy to make a recommendation, because it’s not me wearing the brace,” Dr. Shuster said. “Having those candid conversations with the family about what’s realistic for the child could help compliance.”
Systemic medications
Medications also open a number of questions for families. Some are not readily available in liquid form, some cannot be crushed and some requiring specialty pharmacy compounding. Common medications for systemic spasticity treatment include baclofen and diazepam. A 2016 study comparing baclofen and diazepam found both delivered significant improvement in spasticity and did not demonstrate any statistically significant difference in efficacy between the two medications.
A baclofen pump can deliver the medication continuously. The criteria for a baclofen pump are confirmed spasticity that interferes with quality of life and is not adequately controlled otherwise. Family motivation is needed, as there are multiple follow-ups to refill the pumps.
The pump itself is about the size of a hockey puck, so the child needs to be large enough for it to fit between the pelvis and rib cage.
Refer a patient
Use Norton EpicLink to quickly and easily refer a patient to Norton Children’s Physical Medicine & Rehabilitation.
Focal spasticity management
For more focal spasticity management there are two broad categories of medication: botulinum toxin injections and phenol neurolysis. Botulinum toxin can reduce spasticity, improve passive and active range of motion and reduce pain.
For injection of phenol or other alcohol-based blocks, the child needs to be sedated so the physician can find the precise motor point to deliver the medication. Conversely, botulinum toxins can be injected in a clinic setting without need for anesthesia or sedation. These injections are well tolerated by pediatric patients. Aside from anatomical knowledge, electrical stimulation, electromyography and ultrasound can help direct the best location for the injections.
Additionally, Dr. Schuster advises monitoring hip and spine alignment starting around age 2, then, at least once a year, depending on functional status, taking new images to watch for any progression.
“I tend to refer to orthopedics a bit earlier than is absolutely necessary so families have a relationship with the orthopedist before the time comes to discuss hip surgery or scoliosis fusion if the need arises,” she said.
Watch Dr. Schuster’s Continuing Medical Education presentation “Approach to Therapy and Treatment in Cerebral Palsy” on-demand.