Skip to main content
SpringerLink
Log in

Spasticity, Dystonia, and Athetosis Management in the Upper Extremity in Cerebral Palsy

  • Living reference work entry
  • First Online:
Cerebral Palsy

  • 303 Accesses

Abstract

Upper extremity disability from cerebral palsy (CP) in both children and adults has multiple aspects to the impairment. Increase muscle spasticity and movement disorder are very common and may be predominating symptoms of the impaired limb. It should be noted, however, that these are often combined with muscle contractures, decreased selective motor control, impaired sensibility, and overall ignoring the limb. The topic of upper extremity spasticity has received as much or more attention than lower extremity spasticity in CP. There are multiple mechanisms for assessing spasticity, which is an issue that continues to be unresolved. In addition to spasticity, movement disorders both athetosis and dystonia are relatively common manifestations of the upper extremity impairment. Treatment for upper extremity spasticity includes many different modalities from oral medication, botulinum toxin injection, electrical stimulation, neurectomy, therapy, and transcranial stimulation. Treatment for movement disorders includes oral medication, intrathecal baclofen, and deep brain stimulation. For the whole population of all children with cerebral palsy, approximately 60% have significant upper extremity disability. The vast majority of these are individuals with spasticity; however approximately 20% also report dyskinetic movement disorders in the upper extremity. The goal for this chapter is to define the treatment options for spasticity and movement disorders in the upper extremity of individuals with CP. The risks, complications, and longer-term expectations of these management strategies will also be discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  • Albright AL (1996a) Baclofen in the treatment of cerebral palsy. Neurology 11:77–83. SRC – GoogleScholar

    CAS  Google Scholar 

  • Albright AL (1996b) Intrathecal baclofen in cerebral palsy movement disorders. Neurology 11(Suppl 1):S29–S35. SRC – GoogleScholar

    Google Scholar 

  • Albright AL, Cervi A, Singletary J (1991) Intrathecal baclofen for spasticity in cerebral palsy [see comments]. JAMA 265:1418–1422. SRC – GoogleScholar

    Article  CAS  PubMed  Google Scholar 

  • Aravamuthan BR, Waugh JL (2016) Localization of basal ganglia and thalamic damage in dyskinetic cerebral palsy. Pediatr Neurol 54:11–21

    Article  PubMed  Google Scholar 

  • Aree-uea B, Auvichayapat N, Janyacharoen T, Siritaratiwat W, Amatachaya A, Prasertnoo J, Tunkamnerdthai O, Thinkhamrop B, Jensen MP, Auvichayapat P (2014) Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation. J Med Assoc Thail 97:954–962

    Google Scholar 

  • Arner M, Eliasson AC, Nicklasson S, Sommerstein K, Hagglund G (2008) Hand function in cerebral palsy. Report of 367 children in a population-based longitudinal health care program. J Hand Surg [Am] 33:1337–1347

    Article  Google Scholar 

  • Austin A, Lin JP, Selway R, Ashkan K, Owen T (2017) What parents think and feel about deep brain stimulation in paediatric secondary dystonia including cerebral palsy: a qualitative study of parental decision-making. Eur J Paediatr Neurol 21(1):185–192

    Google Scholar 

  • Autti-Ramo I, Larsen A, Taimo A, von Wendt L (2001) Management of the upper limb with botulinum toxin type A in children with spastic type cerebral palsy and acquired brain injury: clinical implications. Eur J Neurol 8(Suppl 5):136–144

    Article  PubMed  Google Scholar 

  • Beck AJ, Gaskill SJ, Marlin AE, J. (1993) Improvement in upper extremity function and trunk control after selective posterior rhizotomy. Am Ther 47:704–707. SRC – GoogleScholar

    CAS  Google Scholar 

  • Ben-Pazi H (2011) Trihexyphenidyl improves motor function in children with dystonic cerebral palsy: a retrospective analysis. J Child Neurol 26:810–816

    Article  PubMed  Google Scholar 

  • Buckon CE, Thomas S, Aiona MD, Piatt JH (1996) Sienko assessment of upper-extremity function in children with spastic diplegia before and after selective dorsal rhizotomy. Dev Med Child Neurol 38:967–975. SRC – GoogleScholar

    Article  CAS  PubMed  Google Scholar 

  • Chin TY, Duncan JA, Johnstone BR, Graham HK (2005) Management of the upper limb in cerebral palsy. J Pediatr Orthop B 14:389–404

    Article  PubMed  Google Scholar 

  • Corry IS, Cosgrove AP, Walsh EG, McClean D, Graham HK (1997) Botulinum toxin A in the hemiplegic upper limb: a double-blind trial [see comments]. Dev Med Child Neurol 39:185–193. SRC – GoogleScholar

    Article  CAS  PubMed  Google Scholar 

  • De Rinaldis M, Losito L, Gennaro L, Trabacca A (2010) Long-term oral baclofen treatment in a child with cerebral palsy: electroencephalographic changes and clinical adverse effects. J Child Neurol 25:1272–1274

    Article  PubMed  Google Scholar 

  • Fehlings D, Rang M, Glazier J, Steele C (2001) Botulinum toxin type A injections in the spastic upper extremity of children with hemiplegia: child characteristics that predict a positive outcome. Eur J Neurol 8(Suppl 5):145–149

    Article  PubMed  Google Scholar 

  • Fitoussi F, Ilharreborde B, Presedo A, Souchet P, Pennecot GF, Mazda K (2010) Shoulder external rotator selective neurotomy in cerebral palsy: anatomical study and preliminary clinical results. J Pediatr Orthop B 19:71–76

    Article  PubMed  Google Scholar 

  • Fletcher NA, Thompson PD, Scadding JW, Marsden CD (1993) Successful treatment of childhood onset symptomatic dystonia with levodopa. J Neurol Neurosurg Psychiatry 56:865–867

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Francisco GE (2006) Successful treatment of posttraumatic hemiballismus with intrathecal baclofen therapy. Am J Phys Med Rehabil 85:779–782

    Article  PubMed  Google Scholar 

  • Gilmartin R, Bruce D, Storrs BB, J. (2000) Intrathecal baclofen for management of spastic cerebral palsy: multicenter trial. Neurology 15:71–77. SRC – GoogleScholar

    CAS  Google Scholar 

  • Gooch JL, Patton CP (2004) Combining botulinum toxin and phenol to manage spasticity in children. Arch Phys Med Rehabil 85:1121–1124

    Article  PubMed  Google Scholar 

  • Goyal V, Laisram N, Wadhwa RK, Kothari SY (2016) Prospective randomized study of oral diazepam and baclofen on spasticity in cerebral palsy. J Clin Diagn Res 10:RC01–RC05

    CAS  PubMed  PubMed Central  Google Scholar 

  • Gracies JM, Elovic E, McGuire J, Simpson DM, Part I (1997) Traditional pharmacological treatments for spasticity. Local Treat Muscle Nerve Suppl 6:S61–S91. SRC – GoogleScholar

    Article  CAS  PubMed  Google Scholar 

  • Hagglund G, Wagner P (2008) Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 9:150

    Article  PubMed  PubMed Central  Google Scholar 

  • Halpern R, Gillard P, Graham GD, Varon SF, Zorowitz RD (2013) Adherence associated with oral medications in the treatment of spasticity. PM R 5:747–756

    Article  PubMed  Google Scholar 

  • Hansel DE, Hansel CR, Shindle MK, Reinhardt EM, Madden L, Levey EB, Johnston MV, Hoon AH Jr (2003) Oral baclofen in cerebral palsy: possible seizure potentiation? Pediatr Neurol 29:203–206

    Article  PubMed  Google Scholar 

  • Hoon AH Jr, Freese PO, Reinhardt EM, Wilson MA, Lawrie WT Jr, Harryman SE, Pidcock FS, Johnston MV (2001) Age-dependent effects of trihexyphenidyl in extrapyramidal cerebral palsy. Pediatr Neurol 25:55–58

    Article  PubMed  Google Scholar 

  • Hurvitz EA, Conti GE, Brown SH (2003) Changes in movement characteristics of the spastic upper extremity after botulinum toxin injection. Arch Phys Med Rehabil 84:444–454

    Article  PubMed  Google Scholar 

  • Jan MM (2004) Misdiagnoses in children with dopa-responsive dystonia. Pediatr Neurol 31:298–303

    Article  PubMed  Google Scholar 

  • Jethwa A, Mink J, Macarthur C, Knights S, Fehlings T, Fehlings D (2010) Development of the hypertonia assessment tool (HAT): a discriminative tool for hypertonia in children. Dev Med Child Neurol 52:e83–e87

    Article  PubMed  Google Scholar 

  • Jones MH (1953) What’s new in cerebral palsy. Calif Med 79:357–361

    PubMed  PubMed Central  Google Scholar 

  • Kamal N, Bhat DP, Carrick E (2006) Dopa-responsive dystonia (Segawa syndrome). Indian Pediatr 43:635–638

    PubMed  Google Scholar 

  • Kamper DG, Yasukawa AM, Barrett KM, Gaebler-Spira DJ (2006) Effects of neuromuscular electrical stimulation treatment of cerebral palsy on potential impairment mechanisms: a pilot study. Pediatr Phys Ther 18:31–38

    Article  PubMed  Google Scholar 

  • Koy A, Hellmich M, Pauls KA, Marks W, Lin JP, Fricke O, Timmermann L (2013) Effects of deep brain stimulation in dyskinetic cerebral palsy: a meta-analysis. Mov Disord 28:647–654

    Article  PubMed  Google Scholar 

  • Koy A, Pauls KA, Flossdorf P, Becker J, Schonau E, Maarouf M, Liebig T, Fricke O, Fink GR, Timmermann L (2014) Young adults with dyskinetic cerebral palsy improve subjectively on pallidal stimulation, but not in formal dystonia, gait, speech and swallowing testing. Eur Neurol 72:340–348

    Article  PubMed  Google Scholar 

  • Loewen P, Steinbok P, Holsti L, MacKay M (1998) Upper extremity performance and self-care skill changes in children with spastic cerebral palsy following selective posterior rhizotomy. Pediatr Neurosurg 29:191–198. SRC – GoogleScholar

    Article  CAS  PubMed  Google Scholar 

  • Mackey AH, Walt SE, Lobb G, Stott NS (2004) Intraobserver reliability of the modified Tardieu scale in the upper limb of children with hemiplegia. Dev Med Child Neurol 46:267–272

    Article  PubMed  Google Scholar 

  • Marks WA, Honeycutt J, Acosta F Jr, Reed M, Bailey L, Pomykal A, Mercer M (2011) Dystonia due to cerebral palsy responds to deep brain stimulation of the globus pallidus internus. Mov Disord 26:1748–1751

    Article  PubMed  Google Scholar 

  • Marks W, Bailey L, Reed M, Pomykal A, Mercer M, Macomber D, Acosta F Jr, Honeycutt J (2013) Pallidal stimulation in children: comparison between cerebral palsy and DYT1 dystonia. J Child Neurol 28:840–848

    Article  PubMed  Google Scholar 

  • Monbaliu E, Ortibus E, Roelens F, Desloovere K, Deklerck J, Prinzie P, de Cock P, Feys H (2010) Rating scales for dystonia in cerebral palsy: reliability and validity. Dev Med Child Neurol 52:570–575

    Article  CAS  PubMed  Google Scholar 

  • Monbaliu E, De Cock P, Mailleux L, Dan B, Feys H (2017) The relationship of dystonia and choreoathetosis with activity, participation and quality of life in children and youth with dyskinetic cerebral palsy. Eur J Paediatr Neurol 21(2):327-335

    Google Scholar 

  • Montane E, Vallano A, Laporte JR (2004) Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review. Neurology 63:1357–1363

    Article  CAS  PubMed  Google Scholar 

  • Numanoglu A, Gunel MK (2012) Intraobserver reliability of modified Ashworth scale and modified Tardieu scale in the assessment of spasticity in children with cerebral palsy. Acta Orthop Traumatol Turc 46:196–200

    Article  PubMed  Google Scholar 

  • Ozer K, Chesher SP, Scheker LR (2006) Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Dev Med Child Neurol 48:559–563

    Article  PubMed  Google Scholar 

  • Park HS, Kim J, Damiano DL (2012) Development of a Haptic Elbow Spasticity Simulator (HESS) for improving accuracy and reliability of clinical assessment of spasticity. IEEE Trans Neural Syst Rehabil Eng 20:361–370

    Article  PubMed  PubMed Central  Google Scholar 

  • Reeuwijk A, van Schie PE, Becher JG, Kwakkel G (2006) Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review. Clin Rehabil 20:375–387

    Article  PubMed  Google Scholar 

  • Romito LM, Zorzi G, Marras CE, Franzini A, Nardocci N, Albanese A (2015) Pallidal stimulation for acquired dystonia due to cerebral palsy: beyond 5 years. Eur J Neurol 22:426–e32

    Article  CAS  PubMed  Google Scholar 

  • Saintyves G, Genet F, Allieu Y, Judet T, Denormandie P (2011) Surgical management of spasticity of the intrinsic muscles of the long fingers in adults after cerebral palsy, 68 operated hands. Chir Main 30:46–51

    Article  CAS  PubMed  Google Scholar 

  • Sanger TD, Bastian A, Brunstrom J, Damiano D, Delgado M, Dure L, Gaebler-Spira D, Hoon A, Mink JW, Sherman-Levine S, Welty LJ, Group Child Motor Study (2007) Prospective open-label clinical trial of trihexyphenidyl in children with secondary dystonia due to cerebral palsy. J Child Neurol 22:530–537

    Article  PubMed  Google Scholar 

  • Satila H, Kotamaki A, Koivikko M, Autti-Ramo I (2006) Upper limb function after botulinum toxin A treatment in cerebral palsy: two years follow-up of six cases. Pediatr Rehabil 9:247–258

    Article  PubMed  Google Scholar 

  • Speth L, Janssen-Potten Y, Leffers P, Rameckers E, Defesche A, Winkens B, Becher J, Smeets R, Vles JS (2015) Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity impairments in unilateral cerebral palsy: an explorative study. Eur J Paediatr Neurol 19:337–348

    Article  PubMed  Google Scholar 

  • Taira T, Hori T (2007) Intrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state. Acta Neurochir Suppl 97:227–229

    CAS  PubMed  Google Scholar 

  • Taira T, Hori T (2008) Selective peripheral neurotomy and selective dorsal rhizotomy. Brain Nerve 60:1427–1436

    PubMed  Google Scholar 

  • Taira T, Ochiai T, Goto S, Hori T (2006) Fifteen year experience of intrathecal baclofen treatment in Japan. Acta Neurochir Suppl 99:61–63

    Article  CAS  PubMed  Google Scholar 

  • Valle AC, Dionisio K, Pitskel NB, Pascual-Leone A, Orsati F, Ferreira MJ, Boggio PS, Lima MC, Rigonatti SP, Fregni F (2007) Low and high frequency repetitive transcranial magnetic stimulation for the treatment of spasticity. Dev Med Child Neurol 49:534–538

    Article  PubMed  Google Scholar 

  • Van Heest AE, Bagley A, Molitor F, James MA (2015) Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg Am 97:529–536

    Article  PubMed  Google Scholar 

  • Wasiak J, Hoare B, Wallen M (2004) Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Cochrane Database Syst Rev: CD003469

    Google Scholar 

  • Yildizgoren MT, Nakipoglu Yuzer GF, Ekiz T, Ozgirgin N (2014) Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy. Pediatr Neurol 51:360–364

    Article  PubMed  Google Scholar 

  • Zancolli EA (2003) Surgical management of the hand in infantile spastic hemiplegia. Hand Clin 19:609–629

    Article  PubMed  Google Scholar 

  • Zonta MB, Bruck I, Puppi M, Muzzolon S, Neto Ade C, Coutinho dos Santos LH (2013) Effects of early spasticity treatment on children with hemiplegic cerebral palsy: a preliminary study. Arq Neuropsiquiatr 71:453–461

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. AI DuPont Hospital for Children, Wilmington, USA

    Freeman Miller

Authors
  1. Freeman Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Alfred I. duPont Institute, Wilmington, Delaware, USA

    Freeman Miller

  2. Cerebral Palsy Program, AI DuPont Hospital for Children , Wilmington, Delaware, USA

    Steven Bachrach

  3. AI DuPont Hospital for Children , Wilmington, Delaware, USA

    Nancy Lennon

  4. Drexel University, PHILADELPHIA, Pennsylvania, USA

    Margaret O'Neil

Section Editor information

  1. AI DuPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this entry

Check for updates. Verify currency and authenticity via CrossMark

Cite this entry

Miller, F. (2018). Spasticity, Dystonia, and Athetosis Management in the Upper Extremity in Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M. (eds) Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-319-50592-3_110-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-50592-3_110-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-50592-3

  • Online ISBN: 978-3-319-50592-3

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation