Treating complex movement disorders in children with cerebral palsy

Cerebral palsy is common, affecting about 2–3 per 1000 children1. These children may have a motor disorder characterised by spasticity, dystonia or both. This can result in significant difficulty with activities of daily living, pain and long term joint deformity2. There are a number of treatments available for the management of spasticity and dystonia. This review will examine indications and practical issues for some of the common treatment options used in the paediatric population such as botulinum toxin and intrathecal baclofen and the newer therapy for dystonia management, deep brain stimulation. Spasticity management in childhood cerebral palsy A definition of spasticity was provided by Lance in 1980, ‘Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (“muscle tone”) with exaggerated tendon jerks, resulting from hyper excitability of the stretch reflex, as one component of the upper motor neurone syndrome’. Spasticity results from a lack of descending impulses that normally stimulate the release of the inhibitory neurotransmitter GABA which acts presynaptically to inhibit the release of excitatory neurotransmitters. Two of the most common causes of spasticity are cerebral palsy and acquired brain injury. Spasticity can result in functional problems with daily activities such as gait, feeding, washing and dressing. Over time it may result in joint contracture and hip dislocation in more severely affected individuals. It is recognised that a painful hip joint can result in poor tolerance of the seated position and may result in the need for frequent turning at night. The discomfort and lack of sleep can exacerbate seizures, dystonic posturing and spasms, the child can present as irritable and unsettled, in some the manifestations of pain include teeth grinding, biting and head banging. Identifying the source of pain and treating it can reduce the need for changes in anticonvulsants and tone modifying agents. However spasticity can also be helping the child to maintain posture and function as underlying muscle strength may be low. Therefore it is important for any treatment to be titratable in order to maintain functional benefits whilst reducing spasticity.