Management of cerebral palsy in adults

Spasticity

Enteral muscle relaxant drug treatments

Enteral baclofen is the first-line drug treatment for adults with cerebral palsy and generalised spasticity causing:

• functional impairment or
• pain or
• spasms.

Enteral baclofen treatment should be started with a low dose and increase the dose gradually over about 4 weeks to achieve the optimum therapeutic effect.

If enteral baclofen is ineffective or not tolerated by adults with cerebral palsy and generalised spasticity:

• refer the person to a tone or spasticity management service or
• discuss other drug treatment options (including other enteral muscle relaxants) with a tone management specialist

Do not offer diazepam for spasticity in adults with cerebral palsy, except in an acute situation when spasticity is causing severe pain or anxiety.

Do not rapidly withdraw muscle relaxant drugs, particularly if adults with cerebral palsy have taken them for more than 2 months or at a high dosage. Reduce the dosage gradually to avoid withdrawal symptoms

Botulinum toxin type A injections

• consider referring adults with cerebral palsy for botulinum toxin type A treatment if: they have spasticity in a limited number of muscle groups that is:
• affecting their care (such as hygiene or dressing) or
• causing pain or
• impairing activity and participation, or
• a tone management specialist agrees that treatment targeted to focal muscle groups is likely to improve their function and symptoms

Neurosurgical treatments to reduce spasticity

These include:

• intrathecal baclofen
• selective dorsal rhizotomy

Dystonia

Refer adults with cerebral palsy and problematic dystonia (for example, causing problems with function, pain or participation) to a tone or spasticity management service to consider treatment options.

Enteral anti-dystonic drug treatments

Do not prescribe levodopa to manage dystonia in adults with cerebral palsy, except in the rare situation when it is used as a therapeutic trial to identify doparesponsive dystonia.

Do not rapidly withdraw enteral drugs for treating dystonia, particularly if adults with cerebral palsy have taken them for more than 2 months or at a high dosage. Reduce the dosage gradually to avoid withdrawal symptoms

Botulinum toxin type A injections

• should only consider botulinum toxin type A treatment for focal dystonia in adults with cerebral palsy when:
  • the person is under the supervision of a tone or spasticity management service, and it
  • is part of a wider programme of therapy and focal dystonia is:
    • affecting their care (such as hygiene or dressing) or
    • causing pain or
    • impairing activity and participation

Neurosurgical treatment to reduce dystonia

Options include:

• intrathecal baclofen
• deep brain stimulation

Osteoporosis and fracture risk

Health care professionals should be aware that low bone mineral density is common in adults with cerebral palsy, particularly in people:

• with reduced mobility orreduced weight bearing
• taking anticonvulsants or proton pump inhibitors
• who have had a previous low-impact fracture.

Consider assessment for risk of fractures secondary to osteoporosis in adults with cerebral palsy. Risk factors to assess include:

• needing help with moving or having to be moved, for example, hoisting
• history of falls
• low BMI
• history of low-impact fractures
• other medical factors, for example steroid use, that may adversely affect bone health

Consider a dual-energy X-ray absorptiometry (DXA) assessment in adults with cerebral palsy who have 2 or more risk factors (see risk factors above), particularly if they have had a previous low-impact fracture.

Consider referring adults with cerebral palsy for specialist assessment and management, for example, to a rheumatology, endocrinology or bone health service, if they have: a high fracture risk or a positive DXA result

Reference:

• NICE (January 2019). Cerebral palsy in adults