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INTRODUCTION
Katharine E. Alter, MD*

Cerebral palsy (CP) is the most common physical disability beginning in childhood, affecting up to 3.5 out of 1000 live births. It is also associated with high rates of epilepsy, chronic pain, and cognitive and speech impairments.1-2 The motor deficits of patients with CP are caused by short-term and longterm changes that follow a static, fixed lesion of the central nervous system (CNS).3 Short-term consequences of the CNS lesion may include paralysis and immobilization of muscles in a shortened position, whereas delayed consequences may include rearrangement of spinal activity resulting in spasticity and muscle overactivity. Together, all of these processes contribute to the contractures that are a hallmark of patients with CP.3-4 These pathophysiological processes contribute to muscle spasticity, functional limitations (eg, restricted ability to perform functional activities), and disability (eg, restricted participation in normal activities).5 In addition, although the CNS lesion typically remains static, the musculoskeletal deformity of CP usually progresses over time as the child develops and may involve the failure of longitudinal muscle growth, fixed contractures, bony torsion, joint instability, and eventual joint dislocation or degenerative changes.6 With age-related and intervention-related changes, muscle involvement becomes more proximal, compensatory mechanisms become less effective, and a corresponding increase in lordosis and hyperflexion of the hip occurs.

Children with CP are managed using a number of physical therapy, medical, and surgical approaches. Botulinum toxin (BoNT) is frequently used to treat localized spasticity in children with CP and is also used in combination with oral agents or operative management approaches to provide relief from symptoms. Until recently, BoNT was not specifically approved by the US Food and Drug Administration (FDA) for pediatric use. In August 2016, abobotulinum toxin A was approved for use in children with CP (2 years of age and older) to manage lower-limb spasticity.7 Recommended doses are 10 U to 15 U/kg body weight per limb and a upper limit of 15 U to 30 U/kg for unilateral or bilateral injections or 1000 U (whichever is lower).8

The use of BoNT and other treatment options requires a personalized approach that takes into consideration the child’s functional impairments, treatment history, and individual goals. This monograph provides an overview for physical therapists on the assessment and management of children with CP. The first section, by Rebecca Leonard, PT, MS, DPT, PCS, describes the broad range of deficits that are observed in children with CP, including spasticity, pain, abnormal muscle and bone development, and reduced cardiopulmonary function. In the following section, Katharine E. Alter, MD, and Catherine Larsen Coley, PT, DPT, PCS, describe the importance of developing an individualized treatment plan for children with CP as well as some of the physical therapy and medical management approaches that are available to reduce pain and disability as well as help patients achieve their functional goals. In the final section, Sean A. Tabaie, MD, provides an overview of operative approaches in managing children with CP, including neurosurgical interventions (eg, intrathecal baclofen, dorsal root rhizotomy) and orthopedic surgery (eg, muscle and tendon procedures, osteotomy). After completing this monograph, participants should be better able to describe the functional impairments and disability associated with children with CP, steps to consider in developing a personalized treatment plan, and the options that are available for treating this patient population.

*Pediatric/Adult Physiatrist, Mount Washington Pediatric Hospital, Clinical Assistant Professor, Pediatrics, Physical Medicine Rehabilitation, AT Still University, Mesa, Arizona.

Address correspondence to: Katharine E. Alter, MD, Mount Washington Pediatric Outpatient Department, 1708 West Rogers Avenue, Baltimore, MD 21209. E-mail: kalter@cc.nih.gov.

REFERENCES
1. Damiano DL, Alter KE, Chambers H. New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy. Phys Med Rehabil Clin N Am. 2009;20:469-491.
2. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28:183-191.
3. Gracies JM, Elovic E, McGuire J, et al. Traditional pharmacological treatments for spasticity. Part I: Local treatments. Muscle Nerve Suppl. 1997;6:s61-s91.
4. Mathewson MA, Lieber RL. Pathophysiology of muscle contractures in cerebral palsy. Phys Med Rehabil Clin N Am. 2015;26:57-67.
5. American Academy for Cerebral Palsy and Developmental Medicine Web site. Available at: http://www.aacpdm.org/. Accessed July 2017.
6. Graham HK. Botulinum toxin type A management of spasticity in the context of orthopaedic surgery for children with spastic cerebral palsy. Eur J Neurol. 2001;8(suppl 5):30-39.
7. US Food and Drug Administration. New Pediatric Labeling Information Database - Detail: AbobotulinumtoxinA. FDA.gov Web site. Available at: https://www.accessdata.fda.gov/scripts/sda/sdDetailNavigation.cfm?sd=labelingdatabase&id=3C167A0200682FD9E053554DA8C08C7C&rownum=1. Updated September 9, 2016. Accessed November 7, 2016.
8. AbobotulinumtoxinA [package insert]. Basking Ridge, NJ: Ipsen Biopharmaceuticals, Inc; July 2016.



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