Spasticity affects up to 80 % of patients with cerebral palsy (CP) and often plays a significant role in limiting the child’s ability to function and participate in daily activities. The treatment of spasticity involves a multifaceted approach that includes pharmacological treatment with antispasmodics, physical therapy to maintain range of motion and prevent contractures, as well as a variety of orthopedic and neurosurgical interventions. Pharmacological agents currently used in clinical practice to treat spasticity in children have existed for almost two decades and continue to be used despite lack of solid evidence for their efficacy. Studies detailing safety profiles and optimal dosing in the pediatric population are greatly warranted. Intramuscular injection of botulinum neurotoxin is becoming increasingly popular for the treatment of segmental spasticity and current literature suggests it is safe and effective (Level A). Constraint-induced movement therapy (CIMT) and repetitive transcranial magnetic stimulation (rTMS) are emerging as effective interventions in improving motor function in hemiplegic CP. However, the role of these as of yet >interventions in reducing spasticity remains to be clarified.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
Siegel IM. Historical vignette #9. Little big man: the life and genius of William John Little (1810-1894). Orthop Rev. 1988;1156(11):61–6.
Kuban KC, Leviton A. Cerebral palsy. N Engl J Med. 1994;330(3):188–95.
Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol. 2000;42(12):816-24.
Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28(4):183–91.
Sanger TD, Delgado MR, Gaebler-Spira D, et al. Classification and definition of disorders causing hypertonia in childhood. Pediatrics. 2003;111(1):e89–97.
Young RR. Spasticity: a review. Neurology. 1994;44(11 Suppl 9):S12–20.
Beckung E, Hagberg G. Neuroimpairments, activity limitations, and participation restrictions in children with cerebral palsy. Dev Med Child Neurol. 2002;44(5):309–16.
Ramstad K, Jahnsen R, Skjeldal OH, Diseth TH. Characteristics of recurrent musculoskeletal pain in children with cerebral palsy aged 8 to 18 years. Dev Med Child Neurol. 2011;53(11):1013–8.
Persson-Bunke M, Hagglund G, Lauge-Pedersen H, et al. Scoliosis in a total population of children with cerebral palsy. Spine (Phila Pa 1976). 2012;37(12):E708–13.
Bischof FM, Chirwa TF. Daily care activities and hip pain in non-ambulatory children and young adults with cerebral palsy. J Pediatr Rehabil Med. 2011;4(3):219–23.
Brunstrom JE. Clinical considerations in cerebral palsy and spasticity. J Child Neurol. 2001;16(1):10–5.
Tilton A. Management of spasticity in children with cerebral palsy. Semin Pediatr Neurol. 2009;16(2):82–9.
Lynn AK, Turner M, Chambers HG. Surgical management of spasticity in persons with cerebral palsy. Pm R. 2009;1(9):834–8.
Engsberg JR, Ross SA, Wagner JM, Park TS. Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy. Dev Med Child Neurol. 2002;44(4):220–6.
Hoare BJ, Wallen MA, Imms C, et al. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database Syst Rev. 2010; (1):CD003469.
Smania N, Picelli A, Munari D, et al. Rehabilitation procedures in the management of spasticity. Eur J Phys Rehabil Med. 2010;46(3):423–38.
Carranza-del Rio J, Clegg NJ, Moore A, Delgado MR. Use of trihexyphenidyl in children with cerebral palsy. Pediatr Neurol. 2011;44(3):202–6.
Marks WA, Honeycutt J, Acosta Jr F, et al. Dystonia due to cerebral palsy responds to deep brain stimulation of the globus pallidus internus. Mov Disord. 2011;26(9):1748–51.
Chung CY, Chen CL, Wong AM. Pharmacotherapy of spasticity in children with cerebral palsy. J Formos Med Assoc. 2011;110(4):215–22.
Delgado MR, Hirtz D, Aisen M, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010;74(4):336–43. This study involved appraisal of the literature between 1966 and 2008 on the evidence for the safety and efficacy of drugs currently used in clinical practice for the treatment of spasticity in cerebral palsy. The results of this study illustrate that except for diazepam and BoNT-A, there is not enough evidence to refute or support the use of any of the other drugs used (oral and intrathecal baclofen, tizanidine, dantrolene, chemodenervation with phenol, alcohol or BoNT-B). This paper also highlights the need for further studies to evaluate the safety profile and optimal dosing of currently used medications..
Tilton A, Vargus-Adams J, Delgado MR. Pharmacologic treatment of spasticity in children. Semin Pediatr Neurol. 2010;17(4):261–7.
Hoving MA, van Raak EP, Spincemaille GH, et al. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol. 2009;13(3):240–6.
Yadav SL, Singh U, Dureja GP, et al. Phenol block in the management of spastic cerebral palsy. Indian J Pediatr. 1994;61(3):249–55.
Lowe K, Novak I, Cusick A. Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy. Dev Med Child Neurol. 2007;49(11):823–9.
Tedroff K, Granath F, Forssberg H, Haglund-Akerlind Y. Long-term effects of botulinum toxin A in children with cerebral palsy. Dev Med Child Neurol. 2009;51(2):120–7.
Dressler D, Eleopra R. Clinical use of non-A botulinum toxins: botulinum toxin type B. Neurotox Res. 2006;9(2–3):121–5.
Kanellopoulos AD, Mavrogenis AF, Mitsiokapa EA, et al. Long lasting benefits following the combination of static night upper extremity splinting with botulinum toxin A injections in cerebral palsy children. Eur J Phys Rehabil Med. 2009;45(4):501–6.
McLaughlin J, Bjornson K, Temkin N, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002;44(1):17–25.
Josenby AL, Wagner P, Jarnlo GB, et al. Motor function after selective dorsal rhizotomy: a 10-year practice-based follow-up study. Dev Med Child Neurol. 2012;54(5):429–35.
McDonagh MS, Morgan D, Carson S, Russman BS. Systematic review of hyperbaric oxygen therapy for cerebral palsy: the state of the evidence. Dev Med Child Neurol. 2007;49(12):942–7.
Carroll JE, Mays RW. Update on stem cell therapy for cerebral palsy. Expert Opin Biol Ther. 2011;11(4):463–71.
Hidecker MJ, Ho NT, Dodge N, et al. Inter-relationships of functional status in cerebral palsy: analyzing gross motor function, manual ability, and communication function classification systems in children. Dev Med Child Neurol. 2012.
Gunel MK, Mutlu A, Tarsuslu T, Livanelioglu A. Relationship among the Manual Ability Classification System (MACS), the Gross Motor Function Classification System (GMFCS), and the functional status (WeeFIM) in children with spastic cerebral palsy. Eur J Pediatr. 2009;168(4):477–85.
Wiklund LM, Uvebrant P. Hemiplegic cerebral palsy: correlation between CT morphology and clinical findings. Dev Med Child Neurol. 1991;33(6):512–23.
Peurala SH, Kantanen MP, Sjogren T, et al. Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2012;26(3):209–23.
Taub E, Ramey SL, DeLuca S, Echols K. Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics. 2004;113(2):305–12.
Sakzewski L, Ziviani J, Abbott DF, et al. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Dev Med Child Neurol. 2011;53(4):313–20.
Gordon AM. To constrain or not to constrain, and other stories of intensive upper extremity training for children with unilateral cerebral palsy. Dev Med Child Neurol. 2011;53 Suppl 4:56–61.
Morris DM, Taub E. Constraint-induced therapy approach to restoring function after neurological injury. Top Stroke Rehabil. 2001;8(3):16–30.
Martin JH, Chakrabarty S, Friel KM. Harnessing activity-dependent plasticity to repair the damaged corticospinal tract in an animal model of cerebral palsy. Dev Med Child Neurol. 2011;53 Suppl 4:9–13.
Hoare B, Imms C, Carey L, Wasiak J. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a Cochrane systematic review. Clin Rehabil. 2007;21(8):675–85.
Eliasson AC, Krumlinde-sundholm L, Shaw K, Wang C. Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol. 2005;47(4):266–75.
Gordon AM, Charles J, Wolf SL. Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function. Arch Phys Med Rehabil. 2005;86(4):837–44.
Xu K, Wang L, Mai J, He L. Efficacy of constraint-induced movement therapy and electrical stimulation on hand function of children with hemiplegic cerebral palsy: a controlled clinical trial. Disabil Rehabil. 2012;34(4):337–46. In this randomized, single-blind, controlled trial, improvement in hand function was demonstrated in both patients who received CIMT alone as well as those who received both CIMT and electrical stimulation. However, only patients in the combined CIMT and electrical stimulation group showed modest, but significant, decrease in wrist tone. This suggests that improvement in motor function may not necessarily be accompanied by a decrease in spasticity..
Wallen M, Ziviani J, Naylor O, et al. Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial. Dev Med Child Neurol. 2011;53(12):1091–9. This randomized assessor-blinded control trial, mCIMT was shown to be no more effective than intensive OT in improving the child's ability to perform activity of daily living or improving upper extremity function. The data provided also suggests that mCIMT does not result in a considerable change in spasticity as measured by the Tardieu or modified Ashworth scales at 6 months following the intervention..
Berardelli A, Inghilleri M, Rothwell JC, et al. Facilitation of muscle evoked responses after repetitive cortical stimulation in man. Exp Brain Res. 1998;122(1):79–84.
Chen R, Classen J, Gerloff C, et al. Depression of motor cortex excitability by low-frequency transcranial magnetic stimulation. Neurology. 1997;48(5):1398–403.
Kim YH, You SH, Ko MH, et al. Repetitive transcranial magnetic stimulation-induced corticomotor excitability and associated motor skill acquisition in chronic stroke. Stroke. 2006;37(6):1471–6.
Mori F, Koch G, Foti C, et al. The use of repetitive transcranial magnetic stimulation (rTMS) for the treatment of spasticity. Prog Brain Res. 2009;175:429–39.
George MS, Nahas Z, Kozel FA, et al. Improvement of depression following transcranial magnetic stimulation. Curr Psychiatry Rep. 1999;1(2):114–24.
Koh TH, Eyre JA. Maturation of corticospinal tracts assessed by electromagnetic stimulation of the motor cortex. Arch Dis Child. 1988;63(11):1347–52.
Croarkin PE, Wall CA, Lee J. Applications of transcranial magnetic stimulation (TMS) in child and adolescent psychiatry. Int Rev Psychiatry. 2011;23(5):445–53.
Lin KL, Pascual-Leone A. Transcranial magnetic stimulation and its applications in children. Chang Gung Med J. 2002;25(7):424–36.
Valle AC, Dionisio K, Pitskel NB, et al. Low and high frequency repetitive transcranial magnetic stimulation for the treatment of spasticity. Dev Med Child Neurol. 2007;49(7):534–8.
Yasuhara A, Niki T, Ochi A. Changes in EEG after transcranial magnetic stimulation in children with cerebral palsy. Electroencephalogr Clin Neurophysiol Suppl. 1999;49:233–8.
Gilbert DL, Garvey MA, Bansal AS, et al. Should transcranial magnetic stimulation research in children be considered minimal risk? Clin Neurophysiol. 2004;115(8):1730–9.
Collado-Corona MA, Mora-Magana I, Cordero GL, et al. Transcranial magnetic stimulation and acoustic trauma or hearing loss in children. Neurol Res. 2001;23(4):343–6.
Garvey MA, Kaczynski KJ, Becker DA, Bartko JJ. Subjective reactions of children to single-pulse transcranial magnetic stimulation. J Child Neurol. 2001;16(12):891–4.
The authors would like to thank Alba Rinaldi for the necessary secretarial assistance.
No potential conflicts of interest relevant to this article were reported.
About this article
Cite this article
Benini, R., Shevell, M.I. Updates in the Treatment of Spasticity Associated With Cerebral Palsy. Curr Treat Options Neurol 14, 650–659 (2012). https://doi.org/10.1007/s11940-012-0192-7
- Cerebral palsy
- Constraint-induced movement therapy
- Repetitive transcranial magnetic stimulation