Management of Spasticity and Cerebral Palsy Update

Abstract

Cerebral palsy is a very common medical problem, which has many challenges facing patients, family, caregivers, and medical team. The fast-based technology helped us to find new ways to manage and treat cerebral palsy. Treatment and management is a multi-disciplinary approach to reaching the optimal results. The managing team includes a general pediatrician, pediatric neurologist, pediatric rehabilitation, pediatric neurosurgeon, pediatric orthopedic surgeon, and other ancillary medical services. In our management plan, we have to consider the patient, family, and caregivers as parts of our plan. Raising awareness in the communities especially young mothers and general pediatricians to recognize the problem early and seek medical help and also early referrals to specialized centers will help to have early intervention and obtain better results.

1. Introduction

The focus of this chapter is the management of spasticity in CP children by demonstrating the different treatment options available to the child and his/her family. Spasticity was defined by Lance as a “velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex [1].

Treatment for spasticity was documented as early as the late nineteenth century when surgeons Abbe and Bennet discussed decreasing tone in a spastic limb through sensory rhizotomies. Different treatment modalities have been introduced over years to address the complications of spasticity in CP children.

Cerebral palsy (CP) should not be considered as a diagnosis but as a label [2]; it is an umbrella term. The definition is not sufficiently precise to guarantee agreement as to which patients to include under this label, but the additional inclusion criteria required are not yet internationally standardized. It is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.

2. Spasticity management

Cerebral palsy is a difficult condition for many reasons, not least of which is because there is no cure. This neurological condition is caused by brain damage that is irreversible. This does not mean, however, that there is no hope for children diagnosed with cerebral palsy. Spasticity is a common symptom of cerebral palsy. It is characterized by stiff muscles that are difficult to control. In fact, several existing therapies can make a big difference, and there are now numerous emerging treatments that are changing how both children and adults live with cerebral palsy.

2.1 Physical therapy

Physical therapy relieves pain and muscle stiffness, improves mobility, and prevents future problems such as muscle tightness. It is always recommended as the first therapy intervention. It improves motor skills and can stop movement problems from worsening in the future. It includes varieties of treatment modalities such as strength, flexibility exercises, heat treatment, massages, and special equipment for CP children to give them more independence. How much the PT will help to improve the child’s condition depends on the severity and CP type the child has. Mild cases only require some physical therapy. The best chance to improve the child’s condition is with early intervention. Mobility can be improved by preventing contractures and joint dislocations by keeping the body strong and flexible. PT can improve the level of self-reliance of most CP children. The goal of PT is to make everyday movements easier. It can improve coordination, balance, strength, flexibility, endurance, pain management, posture, gait, and overall health.

The benefits of PT depend on the CP type:

• Spastic—It decreases the muscle tension and jerky movements.

• Athetoid—It increases muscle tone and gains more movement control.

• Ataxic—It improves balance problems.

The treatment plan will be based on the CP type. The child might have either hemiplegia, diplegia, or quadriplegia. Therapists design specific exercises and routines for each type, which helps the child regain movement in the affected area over time.

Other conditions such as scoliosis, thoracic kyphosis, lumbar lordosis, pelvic inclination, pelvic rotation, pelvic obliquity, knee deformity, shortened Achilles tendon, and hand and wrist deformities can be treated by PT. After the initial evaluation by the therapist, a treatment plan will be created, which might include a combination of exercises, muscle relaxing techniques, and special equipment to improve movement.

CP child either will have muscle hypotonia or hypertonia. Flexibility exercises and massages are usually used for the hypertonic child, which will develop mobility and prevent painful muscle tightening, which could require surgical intervention. On the other hand, the athetoid child will require strength training exercises to increase their muscle tone. Walking, posture, transitional movements, and sensory impairments such as touch and balance can be improved by certain exercises. Exercises that improve sitting, kneeling, and standing can improve posture. Infants use transitional movements to be able to walk, roll over, and sit up are examples of those movements. Different mobility aids are to be used to make therapy more effective. Different orthotics equipment can be used to help with walking, posture, and joint mobility; braces, casts, splints, and shoe inserts are some examples. There are other tools that have been used in PT include exercise balls, resistance bands, free weights, swimming pools, hot and cold packs, and electric muscle stimulation (it improves gait and upper limb function).

As the child gets older, the physical therapist will change the program to meet the child’s needs. Toddlers and the early school years are the most important stages of a child’s life.

• Toddlers—Playtime is the main therapy focus during this stage. In this stage, children learn and gain experience through play, making it an essential part of early therapy. A therapist can help in certain areas such as overcoming toddlers’ hesitancy to touch their faces or practicing certain movements that are necessary for learning and physical development.

• Young children—School-age children between 5 and 12 experience new movement issues because their bodies are growing. Physical therapy can ensure children to grow in a way that is matching to their motor function. At this stage, therapy will rely on exercises and orthotics. Instilling healthy habits and a proactive mindset is another goal at this stage.

Outcome of the therapy can be evaluated by observation and a set of standardized tests to measure motor function. Therapists will be looking for specific postures and movements that could be corrected to develop a strong treatment plan.

2.2 Occupational therapy

Health care providers usually recommend OT along with PT for CP children to provide easier independent lives because it has many benefits. On one hand, PT improves muscle tone and balance, and on the other hand, OT is helping children to accomplish daily living activities. According to the American Occupational Therapy Association (AOTA), OT helps people of all ages to learn how to improve their abilities to do their everyday activities [3]. Everyday school tasks, eating and drinking, dressing, hygiene, and other tasks necessary for daily use can be assisted by OT. Children with visual impairment, regardless of severity, can do their daily tasks by doing OT. Also, sensory-perceptual-motor (SPM) training, which helps to stimulate the senses of performing daily tasks more easily, can be assisted by OT. An occupational therapist usually uses visual input tools and cues, as well as verbal directions to help children in carrying out necessary everyday tasks. A cognitively impaired child can benefit from OT. Establishing daily schedules or routines to help those children some daily tasks such as remembering to dress, brush their teeth, and other tasks are needed to carry out their day.

The real challenge for CP children is their motor impairment, which makes their daily tasks difficult. For example, most children have difficulties with daily hygiene, moving around, posture, and completing school tasks due to their movement limitations. The occupational therapist will assess every child’s needs individually to design a program to meet their personal goals. The main line of OT program includes stretching and guide motor output techniques and constraint-induced movement therapy (CIMT), which helps hemiplegic CP children [4], and neuromuscular facilitation techniques.

OT can help in other areas such as grasping objects; using computer and other electronics; opening doors; writing, holding, and reading books; playing; interacting with peers, caregivers, and parents; school and/or daycare activities; and sitting and standing up from tables and school desks. CP Children and their parents and caregivers can benefit from OT by watching children thrive both physically and emotionally. This progress reduces parents’ stress and provides a sense of peace as the child becomes more independent and productive.

OT can take place in different settings such as outpatient offices, inpatient medical centers, at home, nursing centers, and OT providers. To obtain quality OT, the child must be under the care and supervision of a trained and licensed occupational therapist. By evaluating the child and assessing the child’s strengths and weaknesses, they will be able to formulate an individualized plan to help the child best reach his or her goals. Per AOTA, licensed occupational therapists, besides they are licensed in their state to practice occupational therapy, have another degree in Social Services, Health, Biology, Chemistry, Psychology, Sociology, Human Development, and Anatomy & Physiology. To obtain their license, they must be graduated from an accredited school, do fieldwork hours, and pass the National Board for Certification in Occupational Therapy examination. The therapist will conduct a comprehensive assessment including testing the child’s: motor skills, developmental condition, cognitive development and functioning, psychological needs, emotional needs, and home and school environment to be able to create an individualized treatment plan.

2.3 Oral medications

Oral medications have been used to decrease spasticity; however, they have a lot of side effects such as drowsiness, sedation, confusion, and fatigue. Benzodiazepines, like diazepam, are rarely used because of their strong sedating effects. They result in enhanced presynaptic inhibition, but because they are presumed to enhance the postsynaptic effects of GABA, they can only work if the GABA-mediated process functions. Benzodiazepines have a long half-life and an active metabolite. Benzodiazepine therapy is indicated in spinal cord injury and multiple sclerosis with possible application in traumatic brain injury, cerebral palsy, and cerebrovascular accident. Clinical effects include sedation and reduced anxiety, decreased resistance to passive range of motion, decreased hyperreflexia, and reduction in painful spasms. Side effects of all benzodiazepines include sedation, weakness, hypotension, gastrointestinal symptoms, memory impairment, incoordination, confusion, depression, and ataxia. Also, benzodiazepines are controlled substances with the potential for dependency. Diazepam is the most widely used benzodiazepine for spasticity management. The recommended initial dose is 2 mg 3 times daily with a maximum dose of 60 mg daily (20 mg 3 times daily). If nocturnal spasticity is the presenting problem, the patient should be started with a single dose at night.

Like benzodiazepines, baclofen works centrally. Baclofen binds with GABA-B receptors on brain and spinal membranes, restricting calcium influx into presynaptic nerve terminals, thereby reducing spasticity. The use of baclofen is indicated when spasticity is of spinal origin. The clinical effects include decreased resistance to passive range of motion, decrease in hyperreflexia, and reduction in painful spasms and clonus. Unlike benzodiazepines and baclofen, dantrolene sodium works peripherally at the level of the muscle fiber. It has no effect on neuromuscular transmission, but works by acting directly on the skeletal muscle, hindering the release of calcium from the sarcoplasmic reticulum, thereby preventing the excitation-contraction coupling mechanism. This affects both intrafusal and extrafusal fibers by decreasing the force of muscle contraction. However, this mechanism is not selective for muscles with increased tone, and the resulting generalized muscle weakness may weaken respiratory muscles. The use of dantrolene sodium is indicated in treating spasticity secondary to cerebrovascular accident and cerebral palsy, and has possible applications for traumatic brain injury, spinal cord injury, and multiple sclerosis. Clinical effects of dantrolene sodium include decreased resistance to passive range of motion, decrease in hyperreflexia and tone, and reduction in spasms and clonus. Another group of oral medications used in spasticity management includes clonidine and tizanidine, which are alpha 2 noradrenergic receptor agonists that release excitatory neurotransmitters and inhibit supraspinal facilitatory pathways [5].

Tizanidine is a new oral anti-spasticity agent that is selective in decreasing tone and spasm frequency in only spastic muscles, eliminating the unwanted side effect of generalized muscle weakness. Tizanidine is reported to have reduced symptoms of spasticity in patients with multiple sclerosis or spinal cord injury and is well tolerated in most patients. It is an imidazoline derivative like clonidine but without the cardiovascular effects when appropriately titrated. Tizanidine results in a direct reduction of excitatory amino acid release from spinal interneurons and inhibits facilitatory cerebrospinal pathways. Its peak effect occurs 1–2 hours following administration and its half-life is 2.5 hours. The clinical effects of tizanidine include reduced muscle tone, spasm frequency, and hyperreflexia. Animal studies with tizanidine demonstrate antinociceptive activity under specific conditions with increased dose titration [6].

As with other anti-spasticity medications, the potential side effects of tizanidine are dose-related and may be mitigated by dosage titration. The potential side effects include drowsiness, dry mouth, and dizziness. Literature suggests that tizanidine may be better tolerated than other anti-spasticity agents as measured by the global tolerance rating scale. In placebo-controlled studies, tizanidine has been shown to be effective in multiple sclerosis and spinal cord injury. It is also useful for spasticity of spinal pathology when weakness is of concern. Tizanidine may also prove effective in managing spasticity of cerebral origin.

Secondary oral and systemic agents include tiagabine, cyproheptadine, clonidine, lamotrigine, gabapentin, and carbidopa-levodopa [7]. Multiple medications have been recommended, of which the most recent addition is gabapentin.

The use of antihypertensive pharmacologic agents in treating spasticity is unclear because randomized trials have not been performed. Nifedipine has been used in a bit-and-swallow technique; more recently, captopril also has been found to be of benefit [8].

Anticholinergic medications are used in CP patients for different issues, such as uncontrollable limb and facial movements, muscle spasms, tremors, and excessive drooling. Anticholinergics block the area of the brain that causes muscle movement [9], which in turn helps to control many of the most common symptoms in CP children. Small doses of anticholinergic medications could be beneficial in some children, whereas other children will require higher dosages. The most common anticholinergics used in CP children include Robinul, Sinemet, benztropine mesylate, and trihexyphenidyl hydrochloride.

Antidepressant medications have been used to improve moods and enhance well-being. These types of drugs are not for everyone, and they have been used in children with depression, anxiety, and other mental and emotional problems that can come from living with a debilitating disorder. Antidepressants are generally used in combination with behavioral therapy [10]. Different antidepressants could be used, but the most commonly have been used are Celexa, Paxil, Prozac, Cymbalta, Lexapro, and Zoloft. Its side effects may differ from patient to patient. Different pain medications have been used, and the most commonly used ones are to control pain by reducing inflammation. Some CP children will experience chronic, long-term pain and anti-inflammatory medicine can be prescribed to relieve their pain. The most common types of anti-inflammatories prescribed to CP patients include nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids. Some parents would rather use natural medications as opposed to traditional drugs, whereas others may try alternatives when the first line of prescribed medications fails to relieve symptoms. Others use a combination of complementary and alternative with conventional medicines. Complementary and alternative medications generally include biologically based supplements, homeopathic medicines, and herbal medicines.

2.4 Speech therapy

Health care providers will recommend speech therapy if the child has communication, swallowing, and breathing issues. Speech therapy provides a wide range of exercises to help children better communicate, address, and help in other disorders affecting speech. A child might have mild to severe speech impairment. However, a study from the National Institute of Neurological Disorders and Stroke (NIH) stated that despite not every CP child had speech impairment, many CP children had some form of speech impairment [11]. A licensed speech therapist evaluates every child to create the optimal individualized plan to help children have better communication. They provide exercises that help children understand gestures, words, numbers, sounds, and more. Also, they help with common problems for CP children such as breathing, swallowing, and digestion issues. They use a variety of exercises such as sign language, communication through writing and painting, winking, voice synthesizers, picture boards, and using augmentative communication devices. Theos’ exercises will improve disorders such as pronunciation skills, vocabulary, development, listening skills, comprehension and formation of words, fluency, direct conversation engagement, and mouth and throat issues. The speech therapist will evaluate every child fully to come up with an individualized based on the child’s needs. Dysphagia is a very common problem in CP children, which is secondary to physiological and neurological disorders, as well as irregularities in the throat. Choking on food and drinks, breathing difficulties, excessive coughing, and pulmonary aspiration of food and fluids must be addressed. Other associated conditions such as stuttering, dysphagia, aphasia, dyspraxia, intonation and rhythm issues, vocal tract problems, and dysarthria must be addressed too. Prevention and reduction ofother associated disorders such as easily choking on foods/liquids, extreme coughing, pulmonary aspiration, difficulties with breathing and dehydration, and malnutrition (typically because of choking on foods/liquids) also have to be one of the therapist’s goals.

Communication is an important human experience, it shapes people’s personalities. Children with communication issues are already at a disadvantage. Proper speech therapy helps the child to overcome their problems and let them communicate better. It will provide the child with the proper ways of communication and help him/her throughout the course of life, including daily living and social activities [12]. It provides other benefits such as learning, the ability to participate fully in school and home activities, better relationship development with friends, peers, and family, better socialization skills, and the ability to communicate ideas consistently and effectively. A master’s degree in speech and language pathology is required to be a speech therapist/speech pathologist, and most states require that they get certified through the American Speech-Language-Hearing Association (ASHA). To obtain ASHA certification, speech pathologists must complete numerous courses dealing with the throat, mouth, speech, psychology, social work, and more [13].

2.5 Massage therapy

CP children can gain mental, emotional, and physical benefits from massage therapy. Massage therapy must be approved by the child’s doctor before starting such a program. Massage therapy supports the treatment of body’s connective tissues and muscles are massaged and stimulated through direct contact by a massage therapist to help healing and well-being of the patient. Direct hand pressure by the therapist will be applied to different body parts. The pressure could be light to heavy, depending on which body part is being stimulated. Therapists can use different types of massage techniques, which are more than 180 techniques with their hands, elbows, arms, and more.

Although the National Institutes of Health (NIH) states that more research is needed before recommending massage therapy to every CP child [14], the American Therapy Massage Association (AMTA) states that anyone can benefit from massage [15]. A published study by the University of Washington and Seattle Children’s Hospital, and Integrative Touch for Kids, showed lessening of painful symptoms by using massage therapy. The study stated, “It is well documented that massage increases blood flow to the tissues and that enhanced blood flow encourages growth of new tissue and healing of wounds” [16].

Massage could stimulate the brain’s pressure receptors when the cranium is massaged and stimulated, it gives a sense of calmness and in return, and the child will be able to focus and concentrate better. Fine and gross motor functioning improves when muscles are relaxed and less rigid. This helps all aspects of CP children’s lives, including playing, socializing, learning, and carrying out daily tasks. Circulation and digestion issues are very common in the CP children. Immobility is the reason for circulation problems; on the other hand, the central and peripheral nervous system structural abnormalities might lead to digestion issues. Relieve tension in the abdominal muscles can help to improve digestion by reducing gassiness and bloating, stimulating peristalsis leading to better digestion, aiding in the release of digestive enzymes, and stimulating kidney and liver activity.

Improving sleep in CP children and adults can be achieved by massage therapy. According to the American Massage Therapy Association (AMTA) and a study published by the National Institutes of Health (NIH), massaging has an essential role in the quality of CP children’s sleep (American Massage Therapy Association | AMTA) [17]”.

Skin, exocrine glands, hair, and nails are the integumentary system of the body’s organ that acts as the first line of defense against outside factors. Skin infections and other integumentary system problems are common in CP children because they cannot care for themselves. This system can be protected by stimulating the skin, improving skin tone and texture, assisting in body temperature regulation, promoting tissue repair, moisturizing skin, removing dead skin, and stimulating sensory receptors.

Massage therapy can be done in physical therapy centers, private massage therapy clinics, hospitals, chiropractic centers, athletic clubs and sports centers, spas, at home, and health clinics. Although massage therapy has shown many benefits, in some instances, it is not advisable. Message therapy is not recommended if the child has muscle and/or joint inflammation, fever, acute infections, skin disorders, open sores, swollen lymph nodes, vaccinations within the past 72 hours, blood clots, diarrhea, osteoporosis, and varicose veins.

Massage therapists cannot give any medical advice regarding your child’s disorder or any other medical issue, psychological counseling, diet or nutrition counseling, touch private parts of the child’s body, perform any type of surgery, and provide skin or cosmetology services. Usually, massage therapy sessions are not covered by insurance, and you might have to pay out-of-pocket expenses.

2.6 Hippotherapy

Hippotherapy is using horses and equine equipment to help CP children to develop better physical, emotional, and neurological functioning. Health care providers usually recommend classical and traditional therapies such as PT and OT, which help to strengthen muscles, improve balance and flexibility, and help with everyday living tasks. On the other hand, hippotherapy can help CP children greatly. It started overseas in the sixties, but it came to the United States after the great benefits it produces. Cognitive ability, neuromuscular problems, physical strength, and a heightened sense of well-being can be improved by hippotherapy [18]. A horse’s movements can be channeled by using equine equipment. Hippotherapy and therapeutic horseback riding are two different therapy modalities to gain different benefits. The gait, rhythm, repetition, and tempo of a horse’s movements have been proven to help with: balance, posture, strength, control, visual cues, sensory, endurance, abnormal muscle tone, social skills, control of the body’s extremities, core strength in the trunk, and self-esteem.

After the health care provider ensures that child mental and physical challenges could benefit from this form of therapy, he/she can recommend hippotherapy. Also, the health care provider and the therapist must agree that the child’s associated disorders will not be affected negatively by the physical challenges of hippotherapy. Hippotherapy can started at any age and has no age limit. Insurance companies usually do not cover the therapy, and you may pay out of pocket for it. A full evaluation of the child’s physical, emotional, and cognitive strength must be done by the therapist to determine if the child is ready for hippotherapy and if any modifications must be provided for the child while sitting on the horse. Safety issues, including how to correctly mount and dismount the horse (with assistance), horse equipment, and what to expect when the horse moves, must be explained by the therapist. After safety training is in place, assisting and monitoring the child during mounting the horse and during the horse’s movements, and walking alongside the horse and child while helping modify the horse’s movements must be done by the therapist to make sure the child is safe. Hippotherapy will help to build physical strength and endurance and improve the child’s well-being and sense of self. The sessions usually take place in horse farms created as specialized training areas. Physical therapists, speech therapists, or occupational therapists can provide the therapy sessions. They must go through extensive hippotherapy training (at least 3 years of their own field of study and 100 hours of hippotherapy training) and have their own certifications. Therapists need to have the following: They must learn in-depth knowledge of horse movement, how to handle emergencies, safety practices, the physical characteristics of horses, the association between human and horse movement and how to choose the appropriate exercises for each child’s individual needs, and more. If the child’s doctor approved the therapy, the therapist has ruled out any conditions that would prevent participation by the therapist.

2.7 Aquatic therapy

Aqua therapy or aquatic therapy is a group of water-based exercises improving a person’s physical abilities and functions. The medical community recommended it as a way to help heal the body [19]. Aquatic therapy has shown improvement in CP children because by allowing them to move freely without putting stress or much weight on their bodies. Water is known to reduce weight by 90%.

Aquatic therapists help CP children to develop more muscle control, increase self-confidence, improve strength and physical function, and gain more life independence. The therapy itself has many physical and mental benefits to CP children. Physical benefits include improved heart function, increased resistance, relief and reduced pain in the joints and muscles, help in protecting against injuries, and reduced discomfort while exercising, help in building muscle and muscle control and better circulation, and improved endurance and flexibility. Mental and emotional benefits include improved confidence, better quality of life, strengthened socialization skills, improved sensory integration, and improved sense of independence.

The severity of the child’s disorder, age, physical fitness level, and any associated illnesses or disorders will determine the best therapy program for the child. Popular aqua therapy exercises include swimming (at all levels, including learning to swim), aquatic yoga, water-based range of motion exercises, balance exercises via flotation devices in deep water, breath control exercises, assisted walking exercises, deep-water walk, and social games to help improve social interaction, eye contact, and sportsmanship. Flotation devices, toys, weights, compression vests, and balls are different equipment used during the aqua therapy session.

Children’s safety is of utmost importance during the aqua sessions. In turn, most pools are generally smaller than standard-size pools and come with fiberglass or stainless-steel shells, built-in attached equipment, safety rails and ladders, thermostat to warm water, and easy-to-grip edges. An active AEA Aquatic Fitness Professional Certification (AFPC) is a requirement for any physical or occupational therapist to carry out the sessions. The session lasts 30 to 45 minutes depending on the child’s individual needs. Kids must bring swimsuits, towels, and water shoes to each session. Some classes may provide these items depending on the program and the family’s financial status.

2.8 Osteopathic manipulation

A trained osteopathic doctor (DO) can provide osteopathic manipulation therapy (OMT) by applying a gentle manipulation of the musculoskeletal system to relieve symptoms and improve overall wellness in patients. The philosophy used by DOs is a holistic, preventative approach with a focus on the musculoskeletal system, how it is linked to disease, and how it can be manipulated for treatment. Despite there being some evidence that OMT can help CP children move better and feel better, the studies are small and have mixed results on how OMT can help those children.

OMT is based on the notion that all body systems are connected, and this connection affects disease and wellness [20]. Osteopathic manipulation therapy is based on a hands-on approach, which is an important part of OMT. DOs use stretching and gentle pressure to manipulate joints and muscles. Musculoskeletal disorders such as back and neck pain or sports-related injuries are common examples of OMT. Some DOs use the technique for different types of conditions, citing a healing touch as crucial to wellness.

OMT has been used as an alternative therapy for CP children complaining of musculoskeletal system symptoms. It is a complementary therapy to more traditional therapies such as PT, OT, surgery, and pain medication to relieve symptoms and pain, improve mobility and reduce spasticity, and more. Cranial osteopathy can be applied to the head and neck. It is a subtle gentle manipulation of the skull that can be used in babies but that can also be used in children and adults.

OMT was studied to see its usefulness in 55 spastic CP children (moderate to severe spasticity) between 20 months and 12 years of age [21]. There were three groups: a control group with no treatment, a group that received acupuncture, and a group that received cranial osteopathic manipulation along with myofascial release. Eleven outcomes were listed as outcomes. The acupuncture group had no significant positive outcomes; on the other hand, the cranial osteopathy group had a positive outcome in two measures (total Gross Motor Function Measurement and the mobility part of the Functional Independence Measure for Children) in comparison with the control group. In another study, thirteen children diagnosed with both cerebral palsy and chronic constipation were studied using OMT. Children were divided into two groups; one group received OMT, while the other group received OMT and traditional medical treatment for constipation. At the conclusion of the study, both groups had equally positive benefits and improvements in constipation [22].

A larger recent study of the use of cranial manipulation in CP children has cast doubt over the treatment’s effectiveness. A British study for 6 months of 142 children using cranial osteopathy. There were two equal numbers of children in each group, and one group received the treatment, while the second group was placed in a control group. The children’s movement was evaluated after 6 months, and there were no statistically significant improvements as compared to the children from the control group [23]. Children’s parents in the treatment group felt that their children had positive gains, in comparison with only a few parents in the control group. Reported positive results by the parents were better sleep, better use of arms and legs, and improved mood [24]. It is not clear if OMT may or may not help CP children, it is different from child to child how it helps. If the therapy is administered by a licensed DO, there is almost no risk of side effects or complications with this type of therapy.

2.9 Chiropractic care

Chiropractic care is a natural type of treatment, which helps several musculoskeletal and nervous system conditions. It is conducted by licensed chiropractors performing different techniques to help reduce pain and spasms and restore proper nervous system function. According to the American Chiropractic Association (ACA), the focus of chiropractic care is the musculoskeletal system disorders and nervous system disorders [25]. The Palmer College of Chiropractic reports that “no part of your body escapes the dominance of your nervous system” [26]. Poor health and improper nervous system functioning could be because of misalignment or other improper functions of the spinal cord and other areas of the body. Treatment focuses on different body parts, like the back, neck, shoulders, hands, and joints in the arms and legs. Despite chiropractors can prescribe certain medications if needed, no medications have been used in the treatment.

Some studies showed neuromuscular and mobility improvement in CP children by using chiropractic care. Some were able to sit up (when they previously could not), walk upstairs without assistance, and use their arms and hands better. Reduction in: Pain and muscle stiffness, breathing problems, drooling, muscle contractions, neck pain, musculoskeletal conditions, gait issues, spine issues, anxiety and stress, headaches and chest pain, leg/arm problems, speech problems due to respiratory issues, spasticity, and urinary incontinence were the improved areas after chiropractic care.

After taking a full medical history, the chiropractor will ask you and/or your child specific questions about pain and any activities that make the pain worse [27]. A physical exam must be done (which could include diagnostic tests such as X-rays or an MRI). The following areas could be studied: neurological integrity, range of motion, muscle tone and strength, abnormalities, misalignment, and flexion-distraction therapy. Treatment will be designed based on the child’s medical history and physical exam results. The most common forms of treatment include spine adjustments, which can include low spine adjustments, full spine adjustments, the “Activator” technique, and/or the “Gonstead” technique, adjustment to joint dysfunctions, massaging, electrical stimulation, traction, heat/cold applications, and myofascial release. Treatment sessions usually are 30 minutes to an hour, depending on the chiropractor’s techniques and the child or family’s concerns or medical issues. For example, lower back pain treatment may require 1–3 visits per week for up to 2–3 months. Sessions could be conducted in hospitals, clinics, or a private provider’s office. Most chiropractors have their own private offices.

Children and parents could get scared during sessions by some maneuvers. Adjustment by the chiropractor could make a popping sound, this does not mean that any bones are broken, and it is from releasing gas from fluids surrounding the joints. Mild discomfort by the child or if the child cries (due to pain) or complains the procedures are too painful, please discuss your concerns with the chiropractor. Chiropractor care usually is not painful. It is very important to choose a well-trained chiropractor by considering his education, training, licensing, and experience working with other healthcare providers and easily coordinating care. The treatment is considered “complementary” care, and it might be not covered by insurance.

2.10 Homeopathy treatment

It can be used to relieve CP children’s difficult symptoms such as relieving pain, improving mobility, and relieving many of the associated symptoms and conditions of CP. Homeopathy is a complete integrated medical system, a complete theory of medical practice that considers a complementary, or alternative, treatment to Western medicine [28]. Homeopathy is a modern alternative medicine like the traditional Chinese medicine, which has evolved over thousands of years. There is a lot of criticism for homeopathy, but many people are claiming it has helped relieve their symptoms. Almost, there are no risks of working with a trained homeopath.

Samuel Hahnemann, a German who created the homeopathy in the 1700s based on the idea that with a little prompting, the body has a remarkable capacity to heal itself. The name homeopathy came from the Greek words “homosis” meaning similar and “pathos” meaning suffering. Homeopathy has two main principles. The first is the idea that like cures like. When a person suffers from a certain symptom, if a substance is triggering that symptom was given to that person, this substance will cure it rather than make it worse. The main idea behind this belief is that the substance will enhance the body’s natural ability to fight the illness or symptom. The second principle is that the treating substance must be given only in very small, dilute amounts, which is thought to be sufficient to trigger.

Remedies extracted from origin such as plants and minerals have been given to patients to treat symptoms and illnesses. Some are toxic and poisonous, like arsenic and belladonna, but others are benign, and all are made with extremely minute amounts of the active ingredient. Some remedies’ formulation has a very low concentration of the active ingredient to be considered chemically insignificant. They come in pill or solution form, and they are over the counter and are regulated by the U.S. Food and Drug Administration.

Some CP children’s symptoms can be relieved by homeopathy; for example, seizure control was described in an article published by the journal, The American Homeopath. Two children failed their anticonvulsant medicines and tried homeopathy to help control their seizures. One boy has severe CP was crippled by seizures and used a variety of over-the-counter remedies for 3 months, and his seizure severity was reduced first and then the frequency. The other case was a severe CP girl and seizures. Homeopathic remedies were used for just over a year. Eight years later she was still seizure-free [29]. A seven-year-old CP boy who was mostly immobile, blind, and incontinent was described in another study. He was on homeopathic treatment for 2 months; he has improvement in his mobility, also he has improvement in his hair lose, became mobile with the help of PT. Other studies have shown either more limited or no results from using homeopathy to treat CP children.

Because the treatment is highly individualized, studying homeopathy is very difficult. Treatment methodology does not allow giving the same remedies to a big group of children having the same symptoms. Many symptoms can be treated with homeopathy. These include mobility, muscle weakness, spasticity, joint pain, digestive issues, and associated conditions (asthma, anxiety, and skin). Homeopathic medicines are safe because they are FDA regulated. There is a strong belief among scientists that remedies have in role in curing or relieving any symptoms because of the very low doses of substances used. Others believe homeopathy has a placebo effect and makes people feel better.

Sessions must be conducting by a trained and certified homeopathic practitioner even there are very limited risks of using homeopathy. Before using homeopathic for your child, you should ask your doctor if there are any reasons you should not try homeopathy. There is a rare risk of side effects or interaction with another medication by using a small amount of active ingredient. Homeopathy has some criticism but also has its supporters. Despite there are limited large-scale studies that prove its efficacy, there are a plenty of case studies. There is plenty of anecdotal evidence and studies showed the benefits to the patients by using this therapy. If your CP child failed the conventional treatments, you might consider consulting a trained homeopathic practitioner.

2.11 Pet therapy

Pet therapy, or animal-assisted therapy, is a complementary therapy for CP children to obtain a lot of benefits from PT and other types of treatment. Working with animals can help CP children reach their goals when added to classic therapies. It is of great importance to work with therapists and animals that are trained and licensed and have experience working with CP children. Pet therapy is the use of well-trained animals to promote wellness, boost mood, and help therapy, and other broad uses in mental and physical health care [30]. There are different ways of pet therapy, either informal or formal. When a trained dog visits a nursing home or hospital to cheer up residents and patients, it is informal. On the other hand, when the animal is the central aid or participant in a guided therapy session, it is formal. Dogs are frequently used in pet therapy but other kinds of animals like cats, horses, and even guinea pigs can be involved.

A study published by the U.S. National Institutes of Health showed that “personal and social benefits gained by dog-assisted therapy may aid in the prevention, improvement, and development of children with various disabilities” [31]. Pet therapy has been used in different situations such as chemotherapy sessions, dental work, and other potentially scary or stressful procedures for children, or even adults, PT sessions to treat injury or a stroke, mental health problems, or for residents in long-term care facilities. It is also commonly used to assist CP children with disabilities.

There are documented benefits of working with animals with special needs of children and adults in formal and informal settings. In mental health cases, being around animals and interacting with them have been shown to lower anxiety, increase relaxation, reduce loneliness, provide comfort, and increase mental stimulation [32]. Physical benefits of working with animals have been well documented, including lowering blood pressure and heart rate, improving cardiovascular health, and reducing pain. Petting and playing with animals have been shown to increase serotonin and reduce cortisol, which together promote less stress in the body.

Having an animal in the PT session for CP children can provide numerous benefits like working with animals during PT helps children reach specific goals, sessions will be less stressful, and children are more engaged and enthusiastic about doing the work. Animals provide good physical support to the children to do their exercises, children prefer using animals than an object for support, and animals motivate children to work harder, meet their goals, and return for subsequent sessions. CP children usually have a lot of mental health issues and behavioral challenges such as ADHD, depression, and anxiety as comorbid conditions. Animals can help improve children’s mood, reduce anxiety, and reduce stress. Benefits of behavioral therapy sessions using animals are motivation, support, encouragement, and someone to bond with and help a child be more engaged and enthusiastic about treatment [33].

One study established a goal for disabled CP children therapy using trained dogs to assist. Results have shown that before therapy children were unable to complete the therapy sessions, but all completed the animal sessions and met their goals after therapy. The animals helped them break down resistance and fear and to carry on with successful therapy sessions.

Children showed improvement in their communication and became better able to tell others what they need or want. They became more sympathetic from working with dogs and they became better able to ask for help and provide help to others. Also, their social skills have improved. Dogs are the most used animals because of how easy they are to be trained and their love of people, but other animals can be trained to work with children with special needs as well. Equine therapy and dolphin therapy have been used as well. Equine therapy may include riding, petting, or caring for horses. The outcome of the sessions relay on the child’s goals but working with horses has the added benefits of getting children outside and improving self-confidence. There are additional potential benefits from the dolphin therapy beside the obtained benefits from other kinds of animals, but it is not common. CP children with mobility issues and pain can be easier to work in the water. However, dolphin therapy is relatively new, and there is little available evidence that it helps. This therapy is expensive but there is an increase in the number of facilities offering this therapy. You should work only with a trained and licensed therapist.

Informal therapy can help CP children who may have to spend time in the hospital for treatments, surgery, and for recovery after surgery by making them more relaxed in a stressful environment. They provide comfort, reduce anxiety, make the hospital setting feel more like home, and offer a feeling of love and acceptance for children who are struggling. Also, children can communicate with and relate better to doctors and nurses. Pet therapy can be a great way for CP children and other disabilities to get more out of their therapy sessions 3.1.

2.12 Pilates

A fully integrated program of exercises using special apparatus, amid to improve physical strength, flexibility, posture, endurance, and mental awareness. It is easy to be used for beginners, they can use it because it does not require heavy weights or strenuous cardiovascular work, it is easy on the joints, and it has many health and fitness benefits. It can be used by all ability levels and can provide a significant strength workout for advanced athletes or a gentler workout for beginners, patients recovering from injury, or those with physical limitations. For CP children and adults, exercise of any type may seem daunting. Physical activity and supervised exercise have many benefits for CP patients as well as healthy people. Pilates is a suitable program to be adopted by people with physical limitations and to improve the CP symptoms while also increasing mobility and range of motion.

Pilates became very popular in the modern area, but it is nearly 100 years old, and it was created by Joseph Pilates in the 1920s. It involves the use of low-impact movements that focus on muscle strength, flexibility, and endurance [33]. Good posture and spinal alignment, balance between muscles, and core strength are the focus. Many moves can be done without equipment, but Pilates machines are used to help do specific movements and exercises.

Physical activity of any type is beneficial for everyone. If workouts routine is created to match an individual’s ability level and limitations, any type of exercise improves cardiovascular health, muscle strength, bone density, and other areas of the body and mind. Great health benefits can be obtained by Pilates, such as greater flexibility, improved balance and posture, reduced back pain, greater strength and stability in the core, improved overall muscle strength, greater muscle endurance, and better mental well-being.

Symptoms of adults and children can be improved by practicing Pilates, but other specific benefits are to be achieved. A child may have trouble to control his muscle movements, and he/she might be able to bend or straighten his/her leg but nothing in between. Guided work on a reformer (Pilates equipment with a sliding frame) could help children develop greater control over their movements. Those exercises can be done while the child is lying down, often in a more comfortable position.

Targeting children’s trunks with physical and strength training could significantly improve mobility and balance, a study showed. Children, before the study started, were not able to sit up by themselves. They were trained using specialized equipment used to target their trunk muscles and hip joints. After several weeks of training, they were better able to control movements and could sit and balance independently. The study did not use Pilates movements, but other studies have demonstrated that Pilates training can improve strength and posture stability in the trunk. Children who used Pilates have the chance to improve their stability, so they are able to sit up much easier, be more stable and balanced, and have greater control over their movements.

There is plenty of anecdotal evidence from personal stories that practicing Pilates can benefit adults and children with physical limitations. Gaining greater strength, posture, and balance between muscles that were previously weaker or stronger than others was described by adults. Stories of children who used Pilates movements in their PT sessions made them more independent, have greater joint range of motion, and have greater muscle strength that was once weak and difficult to control. The improvements in strength, balance, flexibility, and posture all help reduce pain as well [34].

Emotional and mental benefits of using Pilates can be experienced by children. The improvements in a child’s pain and movement using Pilates could be great, and they give a great sense of control, achievement, and even relaxation with less stress. A positive body image can be achieved in all types of people, better with and without disabilities by using Pilates. It is recommended to try Pilates under the supervision of a trained instructor. The movements are generally easy, but it is easy to be done incorrectly. Most of the poses and movements are very specific and it could be of benefit if supervised by a trainer to correct and guide them, especially in CP children. Hospitals, medical centers, and physical therapy centers offer in-house Pilates classes and other types of exercises, so start with your medical team to find out how you can safely get started with Pilates.

2.13 Yoga

Yoga is an ancient practice of mixing physical with spiritual elements. Despite it being old Indian practice, nowadays it became more popular than ever. Stress relief, flexibility, strength, and other health improvements can be achieved by practicing Yoga. It can also be of great help to CP children and adults.

There are few clinical studies on yoga’s effect on CP children. However, benefits were greatly documented from individual stories, anecdotes, and case studies showing Yoga, specially modified for personal needs, can have a positive effect on CP patients’ life quality. While some studies for CP children are inconclusive [35], but evidence that yoga provides health benefits, in general, has been documented. There are different branches of complete yoga practice, like breathing exercises and meditation, but recent practitioners focus on asana, the postures.

Asanas are specific positions that are held for sometimes and that are designed to prepare the body with strength and clarity for meditation. On the one hand, Asanas had classic and original purposes; in recent practice, they provide several physical and mental health benefits. On the other hand, hatha yoga is a series of poses that are held for a period of time with a focus on breathing.

Benefits such as weight loss and better eating habits have been shown in studies of people practicing yoga [36]. Ashtanga and Power Yoga are intense and strenuous, but other forms of Yoga are not. Stimulating metabolism while helping with weight loss and weight management can be achieved by practicing Yoga.

The mindfulness practiced during yoga also helps people eat more mindfully, eating smaller portions, and making better choices. Overall better physical fitness, improved cardiovascular health, and lower blood pressure are proven benefits of Yoga. Yoga like PT improves muscle strength, balance, gain mobility in CP children often modified for a person’s needs, or limitations to help children see benefits. Yoga stretches the body and enhances flexibility, joints range of motion, and over mobility. Yoga especially can stretch the spine and help realign it better [37]. Spine stretching increases the spaces between vertebrae, which in turn decreases pressure on nerves. Less muscular tension and relaxation throughout the whole body is the overall result. Other less tangible benefits for CP children include relaxation, less stress, better body image, and an overall better sense of well-being.

Health care providers should consider Yoga as part of CP children and adults’ treatment plans. Asana postures are not possible to be done as they are described in patients with any degree of physical disability. Only, they must be adapted for patient with a disability to see benefits. Chair yoga is a perfect example of adapted Yoga in CP patients allowing them to enjoy the benefits of Yoga while they are confined to a wheelchair. The positions are modified from the perspective of sitting in a chair like a child with a balance problem can still use a pose, but while sitting. Other yoga adaptations involve different other props, such as blocks or straps, and the help of a trained practitioner or coach who has experience working with disabled patients.

Asanas are the most common yoga type in the west, mindfulness is the most important part of this ancient practice. Yoga users must be mindful by focusing on the body’s posture and breathing while performing the poses, active practice of meditation by sitting still and focusing on the present, most often by focusing on breathing while you are practicing yoga. Meditation can benefit CP children and adults by lowering stress and anxiety, reducing gastrointestinal symptoms, improving sleep, and reducing feelings of depression.

Trying yoga is a good way to see real and positive benefits in CP children. It is very important to work with a professional who is trained in instructing yoga positions and can work with people who have physical disabilities. The poses will need to be adapted and it takes an experienced professional to know how to adapt them to everyone. Despite yoga being an old practice, but nowadays it has been modified and adapted in ways that are varied and positive. Yoga can help CP children to be able to participate in an activity that helps them move better, feel better, and have a greater sense of self-confidence and control. The many benefits of yoga are why every child should give it a try.

2.14 Functional electrical stimulation

It is developed initially to use electrical pulses to stimulate muscles in patients suffering from paralysis. Functional electrical stimulation (FES) currently treating different disorders like CP. It has been tested in clinical trials, and it has been tested for different disorders such as stroke, multiple sclerosis, and CP. In CP children, it is shown to improve range of motion, muscle mass and strength, walking speed, spasticity, gait, and foot and ankle positioning. Still, more research is needed for CP children and other neuromuscular disorders.

FES is a simple technology of a small device that delivers an electrical impulse to a muscle. It is a low-energy current that acts like a tiny shock to activate nerves, which in turn causes the muscle to move [38]. It has been used in paralyzed muscles in a person after an accident who cannot move them. It helps a person with small-scale muscle movements like voiding the bladder and swallowing, as well as with larger movements such as walking, grasping objects, or standing up. Also, it has been used after stroke in a person who has lost some muscle function, and for those with neurological disorders or head injuries. The procedure is safe and not painful because the electrical energy delivered is low. The electrical impulse may cause a little tingling or, sometimes, a slight burning sensation. It is not considered as a lifelong mobility aid, but it is a functional treatment restoring function. Usually, its use is for a short-term to help retrain muscles and restore some degree of voluntary muscle function. Implanted electrical stimulation devices are a new technology helping paralyzed patients to restore some muscle movement.

Spastic CP is very common and accounts for about 70 and 80 percent of all children with CP [39]. Children have painful stiff muscles, and their reflexes are exaggerated. Spastic CP children have different degrees of trouble walking. Commonly, they have involuntary limb movement, continuous muscle spasms, joint contractures, and limited flexibility. Some studies demonstrated that spastic CP children have a better and easy walk by applying FES. In one study 32 children, with an average age of 10 years, received eight weeks of daily functional electrical stimulation to the muscles [40]. There were two groups, an FES group and a control group. Evaluation schedule was at the beginning of the study, eight weeks of treatment, and then six weeks after that. The study has an end point of assessing the children’s ability to walk and their own perceptions of how they walked before. FES group children showed great improvements in how they perceived their ability to walk. They felt that they are walking better and with less pain.

In a hemiplegic spastic CP children study, FES improves gait abnormalities [41]. The children in the study were able to walk using braces. FES has replaced children’s braces or splints. Evaluation was done before and after the treatment, toe-walking and other asymmetries were improved greatly, and all children were able to walk more symmetrically.

Foot drop; There is a common problem in CP children, they have trouble picking up their feet to take steps, and their toes drag while they are walking. They can overcome this by lifting their knee up higher or swinging it outward to be able to elevate the foot off the floor while walking. This can cause pain and other issues later by doing this awkward movement to keep the foot from dragging. Braces or orthotics can correct the foot drop at the expense of the child’s movement limitation. On the other hand, FES shows great promise to treat foot drop in CP children. FES device was used in a group of children for 4 months, and they have gait evaluations periodically. They had no change in the speed of their walk, but there was improvement in their ankle flexion and foot with reduced awkward movements to avoid dragging the toes.

Despite the positive study results of using FES in CP children, still it is not accepted as a common treatment. Currently, enrolling in clinical trials is the only way to get the treatment. Using FES can give a child hope to move free from awkwardness and pain. While the treatment is not widely available, its apparent effectiveness and safety mean that its use will likely become more widespread.

2.15 Chemo-denervation

Chemo-denervation such as using botulinum toxin type A has proved easier, more effective, and less painful for patients. First clinically introduced in the United States in the early 1980s, botulinum toxin is a potent neurotoxin derived from the anaerobic bacteria Clostridium botulinum, but when used in treatment, no serious systemic toxin effects have been reported [42].

The medication is more costly than alcohol or phenol, but the cost is offset by less physician time and the lack of anesthesia. The formation of antibodies has been a concern, but this can be prevented by allowing 2 months to 3 months between injections. Botulinum toxin works by acting in the neuromuscular junction, preventing the release of acetylcholine, which results in functional denervation. It can be given without EMG and anesthesia, does not cause dysesthesias, and is no more painful than an injection of saline solution. Effects are local and last 3 months to 4 months or longer. It is contraindicated during pregnancy, lactation, in individuals with neuromuscular disorders (such as myasthenia gravis), in patients taking aminoglycosides, or in those who have a known allergy to the drug. Adverse effects are not common and are usually associated with the site of injection, such as bleeding, bruising, soreness or redness at the injection site, or diffusion to nearby muscle groups. In patients that do not respond to botulinum toxin, possible reasons should be considered before labeling the patient as unresponsive. Reasons could be related to injection technique, improper toxin storage, or the patient’s individual characteristics. Overall, botulinum toxin has proven clinically to be effective, safe, and less painful than other invasive therapies [43].

Botulinum toxin is available in serotypes A and B, which have different unit potencies, side-effect profiles, and dilution schedules. Both have been used in children with cerebral palsy, although serotype A has been used more extensively. Dosing guidelines have been suggested for botulinum toxin A for adult and pediatric patients. Adult recommendations are available for botulinum toxin B, but studies are ongoing for pediatric patients [44].

Some results suggest that botulinum toxin type A can be effective in reducing muscle tone over a longer period, but not in preventing development of contractures in spastic muscles. Mechanical and functional alterations can arise from the muscle tissue itself even though the nervous system is the site of the primary lesion. The gross mechanical changes occur in skeletal muscle secondary to spasticity and during development of contracture. Muscle stiffness can change for a variety of structural reasons, only one of which is altered fiber length. There is currently no evidence in the literature that muscle fiber length is shortened in contracture or in spastic skeletal muscle. Contracture formation results from inappropriate architectural adaptation of extremity muscles in response to upper motor neuron lesion [45].

Several studies have reported the successful use of botulinum toxin A for the treatment of drooling in children with cerebral palsy, using injection into the submandibular or parotid glands alone or in combination with other agents. In some studies, the beneficial effects have lasted for up to 4 months without serious side effects or disturbances of oral function [46].

Other treatments include chemical neurolysis, in which the nerve conduction is impaired using chemical agents and therapeutic nerve block using phenol or alcohol. The goals of these treatments are to prevent muscle contractures and improve the patient’s function. A common side effect is that after the nerve is injected, alcohol levels measure above the legal limit in children. Other side effects include damage to sensory and motor nerves, pain at injection site, scarring, and dysesthesias. To ensure the correct site, an injection must be made using an electrical stimulator [47].

2.16 Neurosurgical approaches

Another treatment used to alleviate spasticity in children with cerebral palsy is rhizotomy. Studies have shown that performing selective dorsal rhizotomy at a young age can reduce the need for orthopedic surgery [48]. Goals of rhizotomy are decreased tone, increased mobility, and the facilitation of care for the patient; however, the reduction in spasticity cannot be predicted and sometimes results in excessive hypotonia [49]. The procedure is very meticulous, requiring general anesthesia and a neurophysiologist who must be present to identify which nerve is to be severed.

Other neurosurgical approaches include peripheral neurectomy, myelotomy, and dorsal column electrical stimulation.

It has been established that oral baclofen does not cross the blood-brain barrier effectively and that higher doses of the medication result in serious side effects. Intrathecal baclofen results in a greater decrease in spasticity by allowing higher concentrations of baclofen in the cerebrospinal fluid at about 1% of the daily oral dosage [50].

To be considered for intrathecal baclofen pump placement, the patient must have severe lower limb spasticity that does not respond to other less-invasive treatments. The patient must first be given a trial of 50 μg baclofen through a lumbar puncture or spinal catheter. If unresponsive, 75 μg can be tried after 24 hours and a third trial of 100 μg can be tried 24 hours after that, after which if the patient is still unresponsive, he or she must be excluded from the treatment [51]. Implantation lasts 1–2 hours, and the pump is easy to refill subcutaneously. It is programmed by a computer-controlled radiotelemetry programmer that is linked to the pump’s internal computer and selects the rate and pattern of baclofen administration. Complications to intrathecal baclofen include hypersensitivity to baclofen, intolerance to the side effects of baclofen including drug tolerance, cerebrospinal fluid leakage, pump pocket seroma, hematoma, infection, and soft tissue erosion. The objective of intrathecal baclofen is to individualize the patient’s dose and infusion so that the lowest dose that yields the greatest response can be achieved [52]. In comparison, intrathecal baclofen has less complications and side effects than other treatments and more generalized results in both cerebral and spinal spasticity, making intrathecal baclofen the most effective current tool for the treatment of spasticity in non-ambulant individuals. A recent systematic review showed that there was no evidence to support the clinical use of intrathecal baclofen in ambulant individuals with hypertonicity without further rigorous longitudinal studies [17]. As a precaution, families are prescribed diazepam or diazepam rectal as well as oral baclofen to have at home. If there is evidence of withdrawal, one of these medications is administered, and the patient is instructed to go immediately to the emergency department. Although aggressive use of benzodiazepines and oral baclofen may be helpful, recognition, and return to appropriate intrathecal baclofen dosage are essential for rapid recovery [53].

2.17 Orthopedic procedures

Orthopedic procedures are the most frequently performed operations for spasticity. The targets of these operations are muscles, tendons, or bones. Muscles may be denervated and tendons and muscles may be released, lengthened, or transferred. The goals of surgery may include reducing spasticity, increasing range of motion, improving access for hygiene, improving the ability to tolerate braces, or reducing pain. Orthopedic problems that may result from a spastic limb include cubital or carpal tunnel syndrome, spontaneous fracture, dislocation of the hip or knee, and heterotopic ossification.

The most common orthopedic procedure for the treatment of spasticity is a contracture release. In this procedure, the tendon of a muscle that has a contracture is partially or completely cut. The joint is then positioned at a more normal angle, and a cast is applied. Regrowth of the tendon to a new length occurs over several weeks. Serial casting may be used to gradually extend the joint. Following cast removal, physical therapy is used to strengthen the muscles and improve range of motion.

Spastic muscles in the shoulder, elbow, forearm, hands, and legs may all be treated with tendon or muscle lengthening. Spasticity in the shoulder muscles may cause abduction or adduction and internal rotation of the shoulder. Abduction results in difficulties with balance, which then affects walking and transferring, and adduction causes problems when reaching for an object or with hygiene and personal care. An operation known as a slide procedure may be used to lengthen the supraspinatus muscle in an abducted spastic shoulder. With adducted shoulders, the surgeon can perform a release of all four muscles that typically cause this deformity.

In an operation known as a tendon transfer, the orthopedic surgeon moves a tendon from the spot at which it attaches to the spastic muscle. With the tendon transferred to a different site, the muscle can no longer pull the joint into a deformed position. In some situations, the transfer allows improved function. In others, the joint retains passive but not active function. Ankle-balancing procedures are among the most effective interventions.

The goal of surgical-orthopedic treatment, which is basically symptomatic, improve, or facilitate the movement to solve the functional or fixed contractures preventing further rehabilitation, to solve the deformation that reduces or prevents movement, sitting, causing pain as in the cases of hip luxation, or threaten respiration as in cases of severe scoliosis. Subluxation and dislocations of the hip in children with CP are most common in children and adolescents who do not walk. We must bear in mind the saying that every child and adolescent with CP has a hip disorder until proven otherwise. The occurrence of dislocation of the hips makes furniture, hygiene and often causes pain. Requires regular radiological studies to the hips once or twice a year during growth, to discover any hip dislocation at an early stage. Subluxation and luxation of the hips are treated surgically. The decision about surgery should bring those involved in the treatment of patients, carefully weighing hopper performs coarse benefits, and harms of surgery. Surgery is necessary to balance the muscle forces around the hip and normalize abnormal anatomic relationships [54].

Osteotomy and arthrodesis involve operations on the bones and are usually accompanied by operations to lengthen or split tendons to allow for fuller correction of the joint deformity. Osteotomy can be used to correct a deformity that cannot be fixed with other procedures. In an osteotomy, a small wedge is removed from a bone to allow it to be repositioned or reshaped. A cast is applied, while the bone heals in a more natural position. Osteotomy procedures are most used to correct hip displacements and foot deformities. Arthrodesis is a fusing together of bones that normally move independently. This fusion limits the ability of a spastic muscle to pull the joint into an abnormal position. Arthrodesis procedures are performed most often on the bones in the ankle and foot. In triple arthrodesis, the three joints of the foot are exposed, the cartilage is removed, and screws are inserted into the bones, fixing the joints into position. With a short walking cast in place for 6 weeks or until the bones have fully healed, the patient may bear weight immediately after the operation (http://wemove.org/spa/spa_oss.html, 2007).

The risks of developing a structural spinal deformity ranges from 24% to 36% for scoliosis and 50% for lordosis for an average of 4–11 years after selective dorsal rhizotomy [55].

Other principles include single event, multilevel surgery; surgery is delayed if possible (more than 6 years). Spasticity management is used as an adjunct to surgical intervention.

2.18 Intensive suit therapy

Intensive suit therapy is a new and experimental treatment for CP children helping them to improve muscle tone, posture, and movement. Despite more studies being needed to confirm its treatment effectiveness, some therapists offer it to their patients because they feel it is useful as a treatment option. It consists of an orthotic suit that includes a hat, knee pads, and specially designed therapeutic shoes. It also has rings that allow bungee cord-like ropes to be inserted and adjusted according to the child’s height.

The child goes through a group of specific exercises in a therapeutic setting, and the suit brings the body into proper alignment and helps to improve abnormal muscle tone, while the suit is on and the elastic ropes are adjusted. Simply, it retrains the brain to recognize the new, corrected body movements. It reduces ataxia, spasticity, and other symptoms that are typically associated with cerebral palsy.

Different types of suits are available, and each one comes with a specific exercise program and training method, but all work in a similar therapeutic concept. The most common suits are Adeli Suit, NeuroSuit, Polish Suit, and TheraSuit. Some suits, such as the NeuroSuit and TheraSuit, offer elbow pads and gloves, which help to increase the function and strength of the arms. In1971, Russia’s space program, the first suit was used, allowed cosmonauts to keep their normal muscle tone while in a weightless environment. In the late 1960s, the Penguin Suit was invented by the Russian Center for Aeronautical and Space Medicine, and it was reliable and fully functional in helping astronauts to prevent disabilities. In the early 1990s, a similar suit was invented by the Pediatric Institute of the Russian Academy of Medical Sciences for CP children and other neuromuscular disorders. This suit was patented in 1994 and became available for therapeutic use. Other suits were invented later for the same purpose.

School of Physical Therapy at the Pacific University reported some improvement in standing ability in the patients who underwent intensive suit therapy from their program [56]. The same conclusion came from a published study by the National Institutes of Health (NIH) [57]. More research is needed to understand the effectiveness of this therapy. Professor Siemionowa, who was member of the team that invented the “Adeli Suit,” concluded that, after the second or third exercise session, children showed a decrease in their spasticity and diminished hyperkinesis in a study done by his institute. The conclusion of the stay was that the suit has a positive effect on the vestibular system, leading to improvements in balance and spatial awareness. The use of the intensive suit therapy in conjunction with the traditional therapy has proven to be the most beneficial effect. In research published in 2011 by the Online Journal of Health and Allied Sciences, 30 spastic diplegic CP children, ranging from ages 4 to 12 years, were studied by a team of physicians [14]. Children were in a combined program of traditional PT and intensive suit therapy for 2 hours a day, for 3 weeks. Significant improvement in gross motor function was achieved by all the children.

Sessions usually are under the supervision of licensed certified physical therapists, who had hands-on training in intensive suit therapy. The typical day routine consists of tissue massage and warm-ups, sensory integration techniques, proper movement patterns and body alignment, development of motor skills, strengthening exercises, and flexibility, balance, and coordination exercises, but each program may be different according to the therapist. Different rehabilitation techniques can be facilitated by using cables, pulleys, and weights. Children often exercise in safe exercise units, known as “monkey cages” or “spider cages,” in which the pulleys and weights help to isolate movements, thereby strengthening the muscles.

Children with certain medical conditions, such as high blood pressure, heart and circulatory conditions, diabetes, kidney problems, severe scoliosis, hydrocephalus (VP shunt), and uncontrolled seizures, must take their doctor and therapist approval before using the suit therapy.

The cost of intensive suit therapy is an important factor to be considered [58]. It is not covered by most insurance companies, and unfortunately, families have to pay out of pocket to pay it. Because the treatment is still considered experimental, it is not covered by some insurance companies.

2.19 Hyperbaric oxygen therapy

Hyperbaric oxygen therapy gained a lot of interest in the medical community. Despite it is not approved as a treatment option for CP, some private offices offer it to their patients. Hyperbaric oxygen therapy (HBOT) is a chamber that supplies the bloodstream with 100% oxygen, while the patient is inside a pressurized chamber. When the patient is inside the chamber, the air pressure will be increased three times higher than the normal air pressure, allowing the lungs to hold on more oxygen [59]. Oxygen is carried by the blood into the body tissues, the extra oxygen can fight infection, and at the same time, the body will stimulate and release stem cells and growth factors. Extra blood oxygen will restore and correct the tissue function and blood gas levels temporarily.

Currently, results are mixed regarding the benefits of HBOT therapy in CP children. There is a feeling that it will be the future of CP treatment. There is a consensus that HBOT works best in CP cases secondary to a brain injury caused by a lack of oxygen, rather than a genetic or developmental cause [60].

Not everyone agrees about the benefits of HBOT. In fact, some doctors believe that HBOT may do more harm than good to CP children. Published studies for clinical trials of HBOT by the National Institutes of Health (NIH) indicated that despite a minimal decrease in children mortality with traumatic brain injuries, it also increased the chances of a poor functional outcome [61]. There was no significant difference between CP children who received HBOT and a placebo group in published research in the modern drug discovery and NHI. Two clinical trials for CP children, 3–12 years of age. One group received hyperbaric oxygen at 1.75 ATA of 100% oxygen. The second group received slightly pressurized room air. They had daily sessions for 40 days. Both groups showed significant improvements in the following areas: attention, memory, gross motor function, speech, and functional skills. The treatment is not covered by most insurance companies, which does not cover the treatment because it is not considered current, valid treatment for CP.

2.20 The Anat Baniel method and NeuroMovement

The Anat Baniel Method and NeuroMovement is a movement type and brain-based therapy that triggers changes in the brain. Anat Baniel is a psychologist and dancer who became interested in the relationship between movement, the brain, and wellness. She was Dr. Moshe Feldenkrais’s co-worker and father of the Feldenkrais method. Her method is a type of movement therapy used to change connections in the brain and between the brain and body. She created a new unique approach to changing the brain based on this method and name it the Anat Baniel Method (ABM), also known as NeuroMovement. It uses movement to change the brain and stimulate its learning process and ability to adapt. Her team works with disabled children and adults after injuries and strokes. They work with healthy individuals such as athletes, musicians, and others to improve their performance.

Neuroplasticity, or brain plasticity, is the core of the treatment for the brain power to change in response to experiences [62]. The current belief is only infants can have neuroplasticity, which decreases significantly with age. Scientists for a long time thought that current research is proving this assumption wrong [62]. Good and bad changes could happen to the adult brains. Positive impact could happen at any age if this ability can be used, which is the bases of the ABM. The ABM identified certain conditions in which the brain can utilize its plasticity and create new connections and patterns. These are known as the nine essentials and underly NeuroMovement therapy [63].

1. Movement with Attention. Movement helps the brain change but only when accompanied by focus and attention on the body.

2. Slow. To learn a new activity, you must do it slowly. A slow pace focuses the brain and stimulates neural connections.

3. Variation. All learning requires variation. Therefore, children play as they develop. By trying all kinds of new things, they learn.

4. Subtlety. Movements and activities should be subtle so the brain can focus on minute differences.

5. Enthusiasm. By engaging in activities with enthusiasm and joy, the brain understands what is essential.

6. Flexible Goals. The way to achieving a target is not necessarily straight. As with children learning through play and experience, anyone using movement therapy tries many things and adapts as they go along.

7. The Learning Switch. The brain has either a learning or a non-learning mode. Effective therapy requires switching into learning mode.

8. Imagination and Dreams. To see changes, it is important to imagine and dream of the possibilities.

9. Awareness. You must be aware to learn. To trigger the brain to learn and change requires being fully present and aware of surroundings and the body’s sensations.

Few research papers studied this method in CP children. There some studies and personal stories showed that ABM can reverse some disabilities. Different random movements can help a healthy baby to learn and develop. On the other hand, a CP child’s movement is limited, which in turn limits development [63].

The trainer assists the child move in ways that will lead to positive brain changes and greater mobility [63]. The treatment goal is to fix certain body areas or physical defects. For example, spasticity and pain will be decreased by massage and PT for the legs, which in turn make the child’s walks easier. ABM has a different approach based on the brain can learn and change, and the focus is on the brain not on one specific physical issue or defect at a time. As the primary organizing structure, the brain’s ability to adapt impacts physical, emotional, cognitive, and social functions [63]. A child can overcome some of his/her disabilities caused by CP if the brain can change, learn, and form new neural connections. The therapy used by ABM practitioners replaces old neurological patterns with new ones [64]. An important aspect is that the ABM does not try to place children into predetermined developmental milestones. The approach treats each child’s development as unique, and every child goes at his/her own pace.

2.21 Acupuncture

Acupuncture is an old medical practice that started in China almost 8000 years ago. In the United States, it is considered an alternative treatment and it must be studied more to prove its effectiveness, which might help CP children by reducing the child’s symptoms and other associated disorders. The acupuncturists will insert tiny needles into specific areas of the skin. The Chinese mentioned, when the needle inserted in specific areas of the skin, it helps to release the body’s life force, also known as the “qi” (pronounced “chee”) [65]. Releasing the force will relieve pain, help treat illnesses, and improve disabilities. A University of Minnesota’s team reported, the “qi” is located throughout the body with focuses in certain areas, including body fluids, actuation, body limbs, body’s defense system, and eating, drinking, and breathing. Targeting pressure points, or meridians, within the body will trigger the qi. After inserting a needle into the pressure point, little pain will be felt by the patient, and he will feel qi moving throughout the meridians. When problem areas within the body were reached by the qi, it results in healing of the deficiencies.

Acupuncture therapy is relatively a new treatment for CP. Very few in-depth studies including NIH study have been done, but the results are encouraging. Acupuncture may provide great help to CP children and can help with the accompanying associated disorders. It can help with cognitive issues, hearing deficits, speech delays, imitations, pain relief, and improved gross motor functionality. The procedure is done at acupuncture clinics. Acupuncture is not one of the traditional treatment options to treat CP and we need more studies to confirm its effectiveness.

According to the National Center for Complementary and Alternative Medicine (NCCAM), “It is safe for children when therapy is performed by a well-experienced acupuncturist, but 2011 research concluded that a lot of side effects can occur when it is done by poorly trained acupuncturist” [66, 67].

The most side effects are dizziness, pain at the site entry, infections, nerve puncture injuries, fatigue, bruising, muscle twitching, and emotional release, which may lead to crying (this is generally a positive side effect). Bruising and nerve injuries are usually do not occur if the procedure done by a fully trained and licensed acupuncturist. To be qualified to practice acupuncture, the acupuncturist must attend a 3–4-year program accredited by the Accreditation Commission for Acupuncture or Oriental Medicine (ACAOM).

2.22 Medical marijuana

CP has a wide range of symptoms ranging from mild spasticity to the inability to control the limbs and uncontrollable. A lot of research has been done, but the focus is to find different treatments to help, control, or cure the symptoms. Research for studying medical marijuana in CP is limited. Previous studies suggest that it has some benefits, including pain control, reduction of spastic movements, reduction of seizures, and more.

A National Institutes of Health (NIH) study on pain treatment was published in 2011. The study enrolled 83 CP adults, treated with 23 different pain medications, including medical marijuana [68]. The most frequent painful areas reported were the legs, lower back, and hips. Results show that “Marijuana was the most effective treatment to relieve the pain; however, less than 5% of the patients never used it for pain relief.”

The most severe form of CP is spastic quadriplegia, children cannot walk, and their speech is usually severely affected. While their extremities are spastic, the neck muscles may be weak, and they are not able to hold their head up. Pain and communication disorders are common in spastic quadriplegia. We have limited data and limited studies on the use of medical marijuana for spastic quadriplegia symptoms that showed multiple therapeutic benefits could be gained. An NIH published in 2007 on the clinical experience and animal studies demonstrates that the active constituents in marijuana help to control partial seizures, which are common in spastic quadriplegia [69]. A published study in 2014 studied the effect of marijuana in reducing painful muscle spasms in multiple sclerosis, which are very common symptoms in this patient group [70].

Cannabis oil or CBD oil, a derivative substance form of marijuana, has a lot of public attention in recent years, especially after a CNN program on a young girl who used to have more than 50 convulsive seizures per day. The family tried all available treatment options with no control over her seizures, and they used a formulation with a high concentration of CBD oil, now known as “Charlotte’s Web” after their daughter’s first name [71]. Her seizure’s frequency went done to only 2−3 per day after they used the oil for weeks. Later, she was successfully weaned off her anti-seizure medications. She also started to walk, talk, and ride her bicycle, and she was not able to do all of them before. Now, CBD oil was sold by different companies as a treatment not only for CP children’s seizures but also for muscle spasms and chronic pain. It is important to consult with your doctor and to search companies selling the oil before starting your child on any medications. Keep in mind, however, that some state laws and regulations do not allow your doctor to give you a recommendation for CBD treatment.

“Getting high” is a legitimate concern of families considering medical marijuana treatment for their children. According to the author of Stoned: A Doctor’s Case For Medical Marijuana, THC is the compound in marijuana that makes people feel high [72]. THC is found in a very low concentration in most of the marijuana and cannabis oil used in medical compounds, and it does not get the patient high. On the one hand, euphoria and hallucinations are due to THC. You might get high if there is some THC in the marijuana you are using. On the other hand, CBD does not have any of those brain effects. There are some studies that used 300, 400, or 600 milligrams of CBD, which is a large dose with no bad psychological side effects. Medical marijuana and CBD oil generally contain a higher concentration of CBD, which help treat seizures and muscle spasms.

There are non-life-threatening symptoms associated with CP like speech repetition and stuttering. They prevent the patient to communicate more effectively. Speech disorders and impediments, such as stuttering in CP children, can be treated by medical marijuana. Despite the few clinical studies published on medical marijuana and stuttering, but many doctors advocate its use as an effective treatment option for speech problems. L Assistance for Your.

2.23 Stem cell therapy

Stem cell therapy is the new era of finding treatment for different disorders, including CP. Stem cells are body cells that can grow and change into other types of cells. Umbilical cord blood of newborns is the optimal option to access and use, and they can develop into nearly any type of cell in the body. Research gave us great optimism that stem cells can help treat brain disorders by regenerating damaged tissue. There are running clinical trials using cord blood to treat CP children. The results are very hopeful, showing that the use of the stem cells is safe and that it could be useful in treating CP symptoms. It may be proven to be a cure for the condition. CP is currently having no cure, but research is progressing, and emerging treatments are proving that there is hope.

3. Conclusion

To prevent cerebral palsy in infants and, thus, the resulting spasticity, it is important that mothers receive prenatal care during pregnancy, that measures are taken to avoid premature labor, and that special consideration is given to pregnancies involving multiple gestations. Early detection and treatment of neurodegenerative diseases may prevent the development of spasticity as well as detect the underlying diseases that could result in brain injury. If children have conditions that make them susceptible to brain or spinal cord injury or both, safety measures should be taken (i.e., helmets for patients who have frequent seizures). The goals of patient and benefits to the patient are important when considering the path of treatment. In some cases, function will not return, but treatment can result in pain reduction and allow easier management of patient care. Common goals are to decrease pain, prevent or decrease contractures, improve ambulation, facilitate activities of daily living, facilitate rehabilitation participation, save caregiver’s time, improve the ease of care, and increase safety. Appropriate management choices are based on therapeutic objectives. Physical and occupational therapists can play a key role in identifying these objectives. Treatments with the fewest side effects are usually given priority. Both the patient’s and the caregiver’s goals must be considered.

4. Summary

A rehabilitation multidisciplinary team could be a good connection with management. Traditional treatments for spasticity include physical therapy, occupational therapy, and rehabilitation treatments, which complete a number of crucial tasks and specific goals in the treatment of patient with CP, this will promote their sensorimotor development, improve their overall posture and position, and enhance their control of movements in all their daily activities; a lot of physical therapy approaches were based on different theoretical principles though the main target is the management of abnormal muscle tone and improving the range of motion through neurodevelopment therapy, conductive education, constraint-induced movement therapy, etc.

Occupational therapy is a client-centered health profession concerned with promoting health and well-being through occupation, in which the patient is stretched anywhere from once daily to several times per day, but it has only a limited effect on the patient’s spasticity. Rehabilitation treatment options include casting, orthotics or splints, strengthening, electrical stimulation, practice of functional tasks, sensory integration, muscle stretching, and targeted muscle training.

Oral medications can be used to decrease spasticity; however, many have unwanted side effects such as drowsiness, sedation, confusion, and fatigue. Benzodiazepines, such as diazepam, are rarely used because of their strong sedating effects. Other oral medications, such as anticholinergics, anti-seizures, address different issues related to CP children.

Speech therapy is recommended if the child has communication, swallowing, and breathing issues. It offers a wide variety of exercises aimed to help children communicate better, and it also addresses and helps in associated disorders that make speech more difficult.

Massage therapy has proven to offer mental, emotional, and physical benefits. It is a supportive therapy treatment in which the body’s connective tissues and muscles are massaged and stimulated through direct contact by a massage therapist to promote healing and well-being in the patient.

Hippotherapy is another form of therapy that uses horses and equine equipment to help CP children to develop better physical functioning, as well as assistance with emotional and neurological functioning. Those therapies help strengthen muscles, improve balance and flexibility, and help your child with everyday living tasks.

Aqua therapy or aquatic therapy is a sequence of water-based exercises that help improve a person’s physical abilities and functions. It is very useful for CP children because it allows the children to move freely without putting stress or much weight on their bodies. Several goals are to be achieved, including helping kids to develop more muscle control, increase self-confidence, improve strength and physical function, and gain more life independence.

Osteopathic manipulation therapy or OMT is a gentle manipulation of the musculoskeletal system that is supposed to relieve symptoms and improve overall wellness in patients practiced by a trained doctor in osteopathic medicine (DO). Studies results on how OMT can help CP children are mixed, and most of them are small or limited in some way, but there is some evidence that OMT can help CP children move better and feel better.

Chiropractic care for CP children is considered a natural type of treatment that can help with several musculoskeletal and nervous system conditions. Chiropractic intervention is done under a licensed chiropractor who will perform different techniques to help reduce pain and spasms and help to restore proper nervous system function.

Homeopathy is an example of modern alternative medicine such as traditional Chinese medicine, which has evolved over thousands of years. There are a lot of critics of homeopathy, but many people claim it has helped them get relief from symptoms. There are few, if any, risks of working with a trained homeopath.

Pet therapy, or animal-assisted therapy, is another way for CP children to get greater benefits from physical therapy sessions as well as other types of treatment. Working with animals is proven to be beneficial in many ways and, when added to standard therapies, can help children meet their goals. Pet therapy is the use of specially trained animals to promote wellness, boost mood, aid therapy, and other broad uses in mental and physical health care.

Pilates is a system of exercises using special apparatus, designed to improve physical strength, flexibility, posture, endurance, and mental awareness. It is easily adapted to all ability levels and can provide a strenuous strength workout for advanced athletes or a gentler workout for beginners, people recovering from injury, or those with physical disabilities.

Yoga is an ancient practice of mixing physical and spiritual elements. Many people around the world get benefits such as stress relief, flexibility, strength, and other health improvements. Yoga is also being used to help specific populations, like CP children and adults.

Functional electrical stimulation is developed originally to help people with paralysis, using electrical pulses to stimulate muscles, and it is now being used to treat a lot of medical conditions, including cerebral palsy. In CP children, it is proven to improve range of motion, muscle mass, muscle strength, walking speed, spasticity, gait, and foot and ankle positioning.

Chemo-denervation such as using botulinum toxin type A has proved easier, more effective, and less painful for patients. Botulinum toxin is a potent neurotoxin derived from the anaerobic bacteria C. botulinum, but when used in treatment, no serious systemic toxin effects have been reported.

Rhizotomy is used to decrease tone, increased mobility, and facilitation of care for the patient. However, the reduction in spasticity cannot be predicted and sometimes results in excessive hypotonia. Other neurosurgical approaches include peripheral neurectomy, myelotomy, and dorsal column electrical stimulation. Intrathecal baclofen pump therapy is a very effective treatment option for CP children.

Orthopedic procedures are the most frequently performed operations for spasticity. The targets of these operations are muscles, tendons, or bones. Muscles may be denervated and tendons and muscles may be released, lengthened, or transferred. The goals of surgery may include reducing spasticity, increasing range of motion, improving access to hygiene, improving the ability to tolerate braces, or reducing pain.

Intensive suit therapy is a new experimental therapy designed to help CP children by improving muscle tone, posture, and movement. Although more studies are needed to confirm its effectiveness in the long run. The intensive suit therapy consists of an orthotic suit that includes a hat, knee pads, and specially designed therapeutic shoes. It also has rings that allow bungee cord-like ropes to be inserted and adjusted according to the child’s height.

Hyperbaric oxygen therapy is not recognized as a treatment option for cerebral palsy. Hyperbaric oxygen therapy (HBOT) is a chamber that provides pure oxygen into the bloodstream, while the patient lies in a pressurized chamber. While the patient is inside the chamber, the air pressure is increased three times higher than the normal air pressure, making it possible for the lungs to grab more oxygen.

The Anat Baniel Method and NeuroMovement is a type of movement and brain-based therapy that triggers changes in the brain. The ABM uses movement to change the brain and trigger its learning process and ability to adapt. Baniel and her team work with special needs children and adults with limitations, such as those caused by injuries and strokes. They also work with athletes, musicians, and others to help improve performance.

Acupuncture is one of the oldest medical practices. It is an alternative form of treatment in the United States and additional studies are needed to determine its overall effectiveness. Acupuncture may be used to lessen the child’s symptoms and many associated disorders.

Medical Marijuana, cerebral palsy is a life-long disorder, with variety of symptoms ranging from mild spastic movements to the inability to control the limbs and severe seizures. Research on the use of medical marijuana in CP is still limited, but previous studies suggest that it offers a host of benefits, including pain control, reduction of spastic movements, reduction of seizures, and more.

Stem cell therapy is an emerging treatment for different conditions, including cerebral palsy. The umbilical cord blood of newborns is the optimal stem cell to be used. The results are very promising, showing that this emerging treatment is safe and that it may be effective in improving symptoms of cerebral palsy.