Iran J Pediatr

Review Article Aug 2014; Vol 24 (No 4), Pp: 345-351

Management of Spasticity in Children with Cerebral Palsy

Alireza Shamsoddini*1, PhD; Susan Amirsalari2, MD; Mohammad-Taghi Hollisaz1, MD; Alireza Rahimnia3, MD;
Amideddin Khatibi-Aghda1, MD

1Exercise Physiology Research Center, 2Department of Pediatric Neurology, 3Department of Orthopedic Surgery,
Baqiyatallah University of Medical Sciences, Tehran, Iran

Received: Jan 10, 2014; Accepted: Feb 17, 2014; First Online Available: May 09, 2014

Abstract
Cerebral palsy is the most common cause of spasticity and physical disability in children and spasticity is one
of the commonest problems in those with neurological disease. The management of spasticity in children with
cerebral palsy requires a multidisciplinary effort and should be started as early as possible. There are a
number of treatments available for the management of spasticity. This article reviews the variety of options
available for the clinical management of spasticity.

Iranian Journal of Pediatrics, Volume 24 (Number 4), August 2014, Pages: 345-351

Key Words: Cerebral Palsy; Intrathecal Baclofen; Occupational Therapy; Physical Therapy; Rhizotomy; Spasticity

Introduction difficulties for care workers[6].

The paper is based on literature searches in
Cerebral palsy (CP) is defined as a clinical PubMed, ISI Web of Science and Google Scholar
syndrome characterized by a persistent disorder using the key phrases management of spasticity
of posture or movement due to a non-progressive and cerebral palsy, with the emphasis on clinical
disorder of the immature brain[1]. The prevalence studies. Our assessments also rest on our own
of CP is 2 to 2.5 per 1,000 live births[2] and its clinical experience and research at Baqiyatallah
incidence may be increasing secondary to Hospital.
improved care in neonatal intensive care units and Literature Review: There are epidemiological,
improved survival of low birth-weight infants[3]. clinical and review studies about management of
Most children with CP will have spasticity as the spasticity in children with cerebral palsy.
main motor disorder and it can be classified either
according to which body areas is affected:
hemiplegia, diplegia, tetraplegia, or the movement
disorder type: spastic, athetoid, ataxic and
hypotonic cerebral palsy[2,3,5]. Spasticity is a major Definitions of Spasticity
challenge for rehabilitation of children with
cerebral palsy. Spasticity can prevent or hamper Most physicians and therapists working with
function, cause pain, disturb sleep, cause children with cerebral palsy probably feel that
unnecessary complications and present major they can recognize spasticity when they see or feel

* Corresponding Author;
Address: Exercise Physiology Research Center, Baqiyatallah University Medical Sciences, Tehran, Iran
E-mail: alirezaot@bmsu.ac.ir
2014 by Pediatrics Center of Excellence, Childrens Medical Center, Tehran University of Medical Sciences, All rights reserved.

Iran J Pediatr; Vol 24 (No 4), Aug 2014

Published by: Tehran University of Medical Sciences (http://ijp.tums.ac.ir)
346 Management of Spasticity in Children with Cerebral Palsy

it[1]. Spasticity is defined as a velocity dependent Causes of Spasticity

increased resistance to passive muscle stretch, or
alternatively as inappropriate involuntary muscle Spasticity in children can result from any disease
activity associated with upper motor neuron process that affects the upper motor neuron
paralysis[7,8]. Spasticity can result in functional within the central nervous system. Injury to the
problems with daily living activities (ADL) such as upper motor neuron decreases cortical input to
gait, feeding, washing, toileting and dressing[9]. the descending reticulospinal and corticospinal
Over time, spasticity may also cause problems, tracts, which causes weakness, loss of motor
such as muscle pain or spasms, trouble moving in control, and reduction in the number of
bed, difficulty with transfers, poor seating voluntarily active motor units. The reduction of
position, impaired ability to stand and walk, these descending tracts removes the normal
dystonic posturing muscle, contracture leading to inhibition of the reflex arcs within the grey matter
joint deformity, bony deformation, joint of the spinal cord, leading to a hyperactive reflex
subluxation or dislocation and diminished arc and spasticity[13]. While in certain cases there
functional independence. Contractures occur is no identifiable cause, typical causes include
when there is loss of joint motion due to structural problems in intrauterine development (e.g.
changes in the muscles, ligaments and tendons exposure to radiation, infection), asphyxia before
surrounding the joint. Shortening and stiffness of birth, hypoxia of the brain, birth trauma during
the soft tissues make the joint resistant to labor and delivery, and complications in the
stretching and prevent normal movement[4,5,10-12]. prenatal period or during childhood. Infections in
However, spasticity is a benefit for children with the mother, low birth weight (less than 2.0 Kg) is a
cerebral palsy. Increased tone may be useful for risk factor for CP. Also, between 40 and 50% of all
the child. It helps to keep the legs straight, thereby children who develop CP were born prematurely.
supporting the childs weight against gravity. The Premature infants are vulnerable, in part because
child with increased tone in trunk extensors may their organs are not fully developed, increasing
stand and take a few steps. Spasticity may help the risk of hypoxic injury to the brain that may
preserve muscle bulk and bone density (Table manifest as cerebral palsy[14].
1)[11]. The extent and type of spasticity can
fluctuate widely according to position of head and
limbs, fatigue, stress and mood of children. One
limb may have one pattern of spasticity whilst
another may have a different pattern[6]. Measuring Spasticity
The diagnosis of spasticity in children with CP
requires a complete physical examination, with
Table 1: Adverse and beneficial effects of Spasticity
ancillary testing as needed. The physical
Effects of spasticity examination should focus on motor power, muscle
- Abnormal posture tone, active and passive range of motion of joints,
- Difficulty in hygiene and dressing sensation, deep tendon reflexes, station (pelvic
- Difficulty in movements and leg alignment while standing, if there is a
- Difficulty in sitting and transfers
possibility), presence of upper and lower limbs
- Inhibits muscle growth
Negative - Joint subluxation or dislocation deformity, spinal alignment[13]. Mechanical
effects - Leads to contractures instruments and electrophysiological techniques
- Masks contraction in the antagonist can also be used to assess spasticity. Mechanical
- Muscle Pain instruments measuring the resistance of the
- Pressure sores muscle to passive stretch and electrophysiological
- Shortening and stiffness of the soft measures showing the hyper excitability of the
tissues stretch reflex are used only for research
- Extensor tone in the limbs help standing
Positive purposes[15]. One of most important tests in
- Preserve bone density
effects rehabilitation for physical examination of
- Preserve muscle bulk
spasticity is the Ashworth scale (Table 2). Always

Iran J Pediatr; Vol 24 (No 4), Aug 2014

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Shamsoddini A, et al 347

Table 2: Ashworth Scale of Muscle Tone

Ashworth Scale Degree of Muscle Tone
1 No increase in tone
2 Slight increase in tone, catch when limb is moved
3 Marked increase in tone, passive movements difficult
4 Considerable increase in tone, passive movements difficult
5 Affected part is rigid in flexion or extension

test the patient while he or she is in a relaxed Botulinum Toxin

supine position. Passively move the joint rapidly
and repeatedly through the available range of Botulinum toxin (BT) injection is now an
motion and grade the resistance using the established first-line treatment for focal
definitions[8,12,16]. Individual assessment, prefer- spasticity[10,12,20-22]. Botulinum toxin type A
ably with the aid of video clips from before and produces dose-related weakness of skeletal
after treatment, may be useful for assessing muscle by impairing the release of acetylcholine at
effectiveness. One important parameter will the neuromuscular junction. This partially
always be whether the aims of the treatment were interrupts muscle contraction making the muscle
fulfilled. temporarily weaker[20-22]. Muscles commonly
Management of spasticity is a major challenge treated with BT include the gastrocnemius-soleus
to treatment team. Various forms of therapy are complex, hamstrings[10,12], hip adductors and
available to people living with cerebral palsy as flexor synergy muscles of the upper
well as caregivers and parents caring for someone extremity[21,22]. Intramuscular injections can be
with this disability. They can all be useful at all localized by surface landmarks, electromyography
stages of this disability and are vital in a CP stimulation, and/or ultrasound[20,22]. Following
person's ability to function and live more injection, muscle relaxation is evident within 48 to
effectively[17]. There is no standardized approach 72 hours and persists for a period of 3 to 6
to spasticity management of cerebral palsy. But months[23]. Botox injection can help improve a
adequate assessment of the specific impairments childs ability to walk or use hands and allow for a
causing disability is necessary for appropriate better fitting orthotics by reducing spasticity.
interventions to be instituted[18]. The treatment Therapists can take advantage of the time when an
strategy depends on the degree of functional overly powerful muscle is weakened to work on
failure caused by the spasticity and its location. In strengthening the muscle on the opposite side of
general, treatment options for management of the joint (antagonist). Sometimes, casting of the
spasticity in children with cerebral palsy include involved extremity is done after the injection to
oral medications, physical and occupational increase the stretch of the tight muscle[10,12,20-22].
therapy, splinting and casting, chemodenervation
with botulinum toxin or phenol, selective dorsal
rhizotomy, intrathecal baclofen, and orthopedic
surgery[4-6,8,10,11,17,18]. Intrathecal Baclofen
Intrathecal baclofen (ITB) was approved for the
treatment of spasticity of cerebral origin in 1996.
ITB is a surgically implanted system used to
Oral Medications control spasticity by infusing baclofen directly into
the spinal canal and around the spinal cord[24].
Oral medications are a systemic, rather than focal, Baclofen inhibits spasticity by blocking excitatory
treatment for spasticity in children with cerebral neurotransmitters in the spinal dorsal horn. ITB
palsy. Oral medications commonly used in maximizes the dose delivered to spinal receptors
children are baclofen, diazepam, clonazepam, and minimizes the side effects associated with oral
dantrolene and tizanidine[19]. baclofen[25].

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348 Management of Spasticity in Children with Cerebral Palsy

Selective dorsal rhizotomy flexion through the use of AFOs has been found to
improve walking efficiency in children with
Selective dorsal rhizotomy (SDR) derives from late spastic diplegic cerebral palsy[33] and in children
19th century procedures for spasticity. SDR is a with hemiplegic cerebral palsy. When AFO use is
neurosurgical procedure that involves partial compared to barefoot walking, the children's
sensory deafferentation at the levels of L1 through walking patterns are better when wearing
S2 nerve rootlets[26]. After a series of tone AFOs[34]. For children with cerebral palsy who
management with rehabilitation punctuated with tend to walk on their toes, AFOs have been shown
botulinum toxin injections, the child would to improve their ability to move from sit to stand.
probably be around 4 to 5 years old and SDR can However, children with cerebral palsy who are
be considered. A suitable candidate for selective able to stand on a flat foot did not benefit from
dorsal rhizotomy is typified by 1) spasticity is still AFOs for moving from sit to stand as the AFOs
a problem 2) good strength of lower limbs and tended to slow them down[35]. AFOs have also
trunk muscles 3) able to stand straight with good been shown to affect how much energy children
alignment 4) intellectually good enough for with cerebral palsy use to walk. One study found
carrying out training[27]. that children with spastic diplegic cerebral palsy
had lower oxygen needs during walking when
they wore hinged AFOs[36].

Splinting, Casting and Orthoses

Casts, splints, and orthoses are all devices that are
designed to keep the body in a certain position.
These devices are used to prevent or correct
deformities in the spastic limb and/or to help
children with cerebral palsy overcome activity
limitations, such as difficulties with standing and
walking[28,29] and serial casting can improve the
range of movement in a joint that is already
contracted[6]. Serial casting is an intervention
practice that is becoming more commonly used in
occupational therapy practice, in addition to other
treatment modalities/protocols for children with
cerebral palsy to manage spasticity and related
contractures[30]. Serial casting is based on the
premise that shortened muscles maintain the
plasticity for lengthening. Providing a prolonged
Fig. 1: Ankle-foot orthosis (AFO)
stretch offers biomechanical benefits and inhibits
spasticity. But there is a difference between
inhibitive casting and serial casting. in inhibitive
casting only a single static cast is used and the
purpose is to reduce tone rather than lengthen
muscle, thereby improving function[31]. The most Orthopedic Surgery
common type of orthosis is the ankle-foot orthosis
(AFO). AFOs are typically designed to limit Orthopedic surgery is no option for managing
unwanted ankle movements, specifically ankle spasticity. Instead, it is used to help correct the
plantar flexion (foot pointed toward the ground) secondary problems that occur with growth in the
(Fig. 1). AFOs can be fixed (to block ankle face of spastic muscles and poor motion control.
movement) or articulating (to allow for some Those problems include muscle shortening, joints
movement at the ankle)[32]. Preventing plantar contractures and bony deformities[37].

Iran J Pediatr; Vol 24 (No 4), Aug 2014

Published by: Tehran University of Medical Sciences (http://ijp.tums.ac.ir)
Shamsoddini A, et al 349

Occupational Therapy and Physical Conclusion

Therapy
The management of spasticity following a cerebral
Occupational therapy (OT) and physical therapy palsy is complex and is a major challenge to
(PT) are a fundamental part of spasticity treatment team. Initial management should focus
management. Muscle overactivity produces on the elimination of externally exacerbating
muscle shortening and muscle shortening causes. If the spasticity interferes with function,
increases spindle sensitivity. Muscle contracture causes pain, and produces deformity, then clear
and stretch sensitive muscle overactivity are treatment goals should be established.
intertwined. Therefore rehabilitation and physical There is not a standardized approach. The
treatments aimed at lengthening the overactive treatment needs to be evidence-based and
muscles are fundamental. Address both depends on the degree of functional failure caused
shortening and overactivity[38]. There are a by the spasticity and its location. This
number of different dynamic Occupational and management often requires a variety of different
Physical therapy approaches, including the Bobath approaches including oral medications, but
technique[4,5], Sensory integration therapy[5], botulinum toxin, intrathecal baclofen,
poprioceptive neuromuscular facilitation[39] and occupational and physical therapy and often
the Brunnstrom technique[40]. Consider applying surgical interventions such as selective dorsal
various techniques such as ice (cold), heat, rhizotomy and orthopedic surgery.
positioning, stretching exercises and use of
orthotic devices for these purposes. Cold inhibits Conflict of Interest: None
spastic muscles, but the effect is short-lived,
perhaps outlasting the application of the cold by
about half an hour[41]. Paradoxically, heat is also
used for relaxation of a spastic muscle[42]. Position
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