Role of Medications in Cerebral Palsy

Medication in the management of cerebral palsy is an integral part of the holistic management. Although, there is no single medicine is available which can cure cerebral palsy but a large number of associated / co-morbid conditions can be treated efficiently with available medicines.  

Generally the following associated condition with children with Cerebral Palsy can be treated with drugs

• Spasticity
• Involuntary Movements/ Dystonia
• Epilepsy
• Drooling
• Constipation
• Sleep disorder
• GER

Spasticity Management 
More than 80% children with Cerebral Palsy suffer due to pathological Spasticity. Spasticity not only affects the joints, it also limits functional ability. A number of drug works in different ways to inhibit spasticity. Antispastic drugs are also called muscle relaxants.  The muscle relaxants used for treating cerebral palsy work by stopping the muscles from contracting. 

The three primary drugs used in treating spasticity are- Diazepam, Baclofen, and Dantrolene 

Diazepam 
Diazepam is a benzodiazepine, a type of muscle relaxant.

Uses
It reduces generalized spasticity, hyperreflexia and painful muscle spasms. It improves sleep and reduces anxiety. 

Side effects
Sedation, increased drooling, ataxia, cognitive dullness. 

Baclofen
Baclofen  is another muscle relaxant that works in the spinal cord.

Uses
It reduces generalized spasticity, hyper-reflexia and painful muscle spasms. 

Side effects
Weakness, sedation, ataxia, nausea, impaired cognition, orthostatic hypotension, dizziness, depression etc. 

Baclofen Withdrawal Syndrome:
Sudden withdrawal of Baclofen may result in a withdrawal syndrome which can be sometimes potentially serious. The child can have seizures, hallucinations, hyperthermia, dydesthesia, pruritis, or rebound spasticity. In this situation, Baclofen should be re-started 

Dantrolene
Dantrolene is another muscles relaxant. It is useful for symptomatic relief of clonuses. 

Side effects
 Muscle weakness, hepato-toxicity, drowsiness. 

Tizanidine
It is a derivative -alpha-2 adrenergic agonist used as muscle relaxant

Side effects
Sedation, hypotension, depression, dry mouth, dizziness, hepatotoxicity

Flexeril
It is used as muscle relaxant only for short-term use. 

Other agents: Gabapentin, Lamotrigine, Cyproheptadine, Cannabinoid like, Clonidine, etc


Management of Involuntary movements
Anti-cholinergic are prescribed to manage involuntary movements. These drugs improve the body's responses and control 

A limited number of Dopaminergic medicine are available

Generally, dystonia, or dyskinesia movements are due to the misfiring of chemicals in the brain that causes a slight yet uncontrollable muscle spasm. At times, or in different patients, these movements can be severely disabling. 

Two major dopaminergic drugs, which may prove to be helpful in cerebral palsy patients, are Sinemet and Artane. 

Sinemet is a dopaminergic medicine combination of two other drugs: L-dopa and carbidopa. Sinemet has been used successfully for some time in treating abnormal movements in Parkinson's Patient. 

These Anticholinergic and dopaminergic medicines block cholinergic nerve impulses that affect the muscles in the arms, legs, and other parts of the body. These medications help regulate muscle movement and motor function. 


Convulsion (Seizure disorders/ Epilepsy) Management
About one third of children with cerebral palsy generally have epilepsy as one of the associated factors. 

The incidence of epilepsy is more seen in CP spastic hemiplegia. Which is followed by CP spastic quadriplegia  and then CP spastic diplegia 

The mean age of onset of seizures is 18 months. 60% have seizures onset before the age of 1 year. Children with myoclonic seizures and infantile spasms have seizure onset significantly early in life. 

All types of seizures are seen in children with cerebral palsy. 

There is increased risk of epilepsy in children with cerebral palsy if the child has any of the following associated factors: 

• Low birth weight
• Neonatal seizure
• Seizure during first year of life
• Family history of epilepsy
• Severe form of cerebral palsy

Anticonvulsants work in the brain to suppress abnormal or hyperactive brain activity. The seizures suffered by cerebral palsy children are typically caused by overloads of "messages" sent from the brain to the nerves and muscles. Anticonvulsants help in stopping these seizures by blocking these messages. 

Most seizures are either complex-partial or tonic-clonic. Seizures are fairly common in cerebral palsy children, up to one quarter have tonic-clonic seizures and about half of people with cerebral palsy have complex-partial seizures. 

Tonic-clonic seizures usually involve a full loss of motor function. The person falls to the ground after briefly crying out. Their muscles become very tight and stiff and their hands and feet begin to twitch. Afterwards, the person may be confused for some time that can be up to a few weeks. 

A complex partial seizure manifests in varying degrees of severity but is usually marked by a partial lack of consciousness. This may be as slight as being forgetful, but may be as serious as to cause impaired walking. 

Anticonvulsants help stop these seizures in cerebral palsy children. There are different types of anticonvulsant medications available. These anticonvulsants tend to limit the excessive electrical activity that occurs in cerebral palsy related seizures.

Conventional antiepileptic drugs: 
Phenytoin, Phenobarbitone, Carbamazipine, Valporic acid.

Newer antiepileptic drugs: 
Oxcarbazepine, Gabapentine, Lamotrizine, Clobazam, Topramate, Levitiracetam, Zonisamide, Pregabalin, Tiagabine, Vigabatrin. 

Side effects of anticonvulsant medication include

• Drowsiness
• Dizziness
• Irritability
• Confusion
• Vomiting
• Uncontrolled eye movements
• Gingivitis
• Itching

Rash

Discontinuation of antiepileptic drugs (AED) in children with cerebral palsy can and should be practiced when possible after patients have been seizure free for at least 2 years. AED discontinuation in children with spastic hemi paresis is significantly more likely to lead to seizures relapse than children with other form of cerebral palsy. 

It is often difficult to control seizures particularly if the child has Intellectual Disability / GDD as an associated factor. 

Polytherapy commonly used in children with cerebral palsy and seizures. 

Long term use of AED which might predispose to osteoporosis is very important issue in cerebral palsy. 

Before starting medicines for epilepsy, it is necessary to diagnose the kind and severity of the seizures as some other common condition can mimic as seizures. Such as: breathe holding spell, gastro esophageal reflux, syncope, movement disorders, behavioral events and parasomnias. 

Drooling
Drooling is unintentional involuntary spillage of saliva from the mouth. A major associated disorder with cerebral palsy. It has considered as psycho-social consequences also such as social stigmatization and emotional devastation for the child and families. 

Causes
It is commonly caused by poor oral facial and bulbar muscles control. The major contributing factors are: hyper secretion of saliva, dental mal-occlusion, postural problems, and inability to recognize salivary spill, mouth breathing, excitement and impaired concentration, lack of sensation around the mouth. 

Medication
There are only a few medicines which help reducing drooling. Anticholinergic medicines such as Glycopyrrolate and scopolamine help a little bit. 

Side effects
Mostly these medicines have lot of side effects. 

Recent development in the management of drooling

Botox injection to parotid and sub-mandibular gland can have miraculous improvement in selected cases of drooling

- Surgical procedures such as salivary gland excision, salivary duct ligation, duct rerouting can be done to reduce or eliminate the problem. These kind of surgeries require lot of expertise.

Constipation
Due to poor postures and limited mobility, most of the children with CP have constipation especially children with spastic quadriplegia. As the children with CP starts crawling, the severity of constipation naturally decreases but in some cases, the children require medicinal support.

Causes of Constipation
Usually the causes of constipation are gut dysmotility, lack of mobility, spasticity, etc 

Medicines used in relieving constipation
The following medicines or techniques help

Drugs: Stool softeners, mild laxatives, etc 

Diet modifications (increasing fibers, fruits, and vegetables, fluid

Conclusion-Our Experience
Medication is an integral part of the management of developmental disorders. More than 90% associated / co-morbid factors are appropriately treated with medications.
As we follow combination therapy, we always integrate medicines with habilitation therapies. Good management of the associated disorders can change the prognosis of the condition       

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