**2.9 Chiropractic care**

Chiropractic care is a natural type of treatment, which helps several musculoskeletal and nervous system conditions. It is conducted by licensed chiropractors performing different techniques to help reduce pain and spasms and restore proper nervous system function. According to the American Chiropractic Association (ACA), the focus of chiropractic care is the musculoskeletal system disorders and nervous system disorders [25]. The Palmer College of Chiropractic reports that *"no part of your body escapes the dominance of your nervous system"* [26]. Poor health and improper nervous system functioning could be because of misalignment or other improper functions of the spinal cord and other areas of the body. Treatment focuses on different body parts, like the back, neck, shoulders, hands, and joints in the arms and legs. Despite chiropractors can prescribe certain medications if needed, no medications have been used in the treatment.

Some studies showed neuromuscular and mobility improvement in CP children by using chiropractic care. Some were able to sit up (when they previously could not), walk upstairs without assistance, and use their arms and hands better. Reduction in: Pain and muscle stiffness, breathing problems, drooling, muscle contractions, neck

#### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

pain, musculoskeletal conditions, gait issues, spine issues, anxiety and stress, headaches and chest pain, leg/arm problems, speech problems due to respiratory issues, spasticity, and urinary incontinence were the improved areas after chiropractic care.

After taking a full medical history, the chiropractor will ask you and/or your child specific questions about pain and any activities that make the pain worse [27]. A physical exam must be done (which could include diagnostic tests such as X-rays or an MRI). The following areas could be studied: neurological integrity, range of motion, muscle tone and strength, abnormalities, misalignment, and flexion-distraction therapy. Treatment will be designed based on the child's medical history and physical exam results. The most common forms of treatment include spine adjustments, which can include low spine adjustments, full spine adjustments, the "Activator" technique, and/or the "Gonstead" technique, adjustment to joint dysfunctions, massaging, electrical stimulation, traction, heat/cold applications, and myofascial release. Treatment sessions usually are 30 minutes to an hour, depending on the chiropractor's techniques and the child or family's concerns or medical issues. For example, lower back pain treatment may require 1–3 visits per week for up to 2–3 months. Sessions could be conducted in hospitals, clinics, or a private provider's office. Most chiropractors have their own private offices.

Children and parents could get scared during sessions by some maneuvers. Adjustment by the chiropractor could make a popping sound, this does not mean that any bones are broken, and it is from releasing gas from fluids surrounding the joints. Mild discomfort by the child or if the child cries (due to pain) or complains the procedures are too painful, please discuss your concerns with the chiropractor. Chiropractor care usually is not painful. It is very important to choose a well-trained chiropractor by considering his education, training, licensing, and experience working with other healthcare providers and easily coordinating care. The treatment is considered "complementary" care, and it might be not covered by insurance.

#### **2.10 Homeopathy treatment**

It can be used to relieve CP children's difficult symptoms such as relieving pain, improving mobility, and relieving many of the associated symptoms and conditions of CP. Homeopathy is a complete integrated medical system, a complete theory of medical practice that considers a complementary, or alternative, treatment to Western medicine [28]. Homeopathy is a modern alternative medicine like the traditional Chinese medicine, which has evolved over thousands of years. There is a lot of criticism for homeopathy, but many people are claiming it has helped relieve their symptoms. Almost, there are no risks of working with a trained homeopath.

Samuel Hahnemann, a German who created the homeopathy in the 1700s based on the idea that with a little prompting, the body has a remarkable capacity to heal itself. The name homeopathy came from the Greek words "homosis" meaning similar and "pathos" meaning suffering. Homeopathy has two main principles. The first is the idea that like cures like. When a person suffers from a certain symptom, if a substance is triggering that symptom was given to that person, this substance will cure it rather than make it worse. The main idea behind this belief is that the substance will enhance the body's natural ability to fight the illness or symptom. The second principle is that the treating substance must be given only in very small, dilute amounts, which is thought to be sufficient to trigger.

Remedies extracted from origin such as plants and minerals have been given to patients to treat symptoms and illnesses. Some are toxic and poisonous, like arsenic and belladonna, but others are benign, and all are made with extremely minute amounts of the active ingredient. Some remedies' formulation has a very low concentration of the active ingredient to be considered chemically insignificant. They come in pill or solution form, and they are over the counter and are regulated by the U.S. Food and Drug Administration.

Some CP children's symptoms can be relieved by homeopathy; for example, seizure control was described in an article published by the journal, The American Homeopath. Two children failed their anticonvulsant medicines and tried homeopathy to help control their seizures. One boy has severe CP was crippled by seizures and used a variety of over-the-counter remedies for 3 months, and his seizure severity was reduced first and then the frequency. The other case was a severe CP girl and seizures. Homeopathic remedies were used for just over a year. Eight years later she was still seizure-free [29]. A seven-year-old CP boy who was mostly immobile, blind, and incontinent was described in another study. He was on homeopathic treatment for 2 months; he has improvement in his mobility, also he has improvement in his hair lose, became mobile with the help of PT. Other studies have shown either more limited or no results from using homeopathy to treat CP children.

Because the treatment is highly individualized, studying homeopathy is very difficult. Treatment methodology does not allow giving the same remedies to a big group of children having the same symptoms. Many symptoms can be treated with homeopathy. These include mobility, muscle weakness, spasticity, joint pain, digestive issues, and associated conditions (asthma, anxiety, and skin). Homeopathic medicines are safe because they are FDA regulated. There is a strong belief among scientists that remedies have in role in curing or relieving any symptoms because of the very low doses of substances used. Others believe homeopathy has a placebo effect and makes people feel better.

Sessions must be conducting by a trained and certified homeopathic practitioner even there are very limited risks of using homeopathy. Before using homeopathic for your child, you should ask your doctor if there are any reasons you should not try homeopathy. There is a rare risk of side effects or interaction with another medication by using a small amount of active ingredient. Homeopathy has some criticism but also has its supporters. Despite there are limited large-scale studies that prove its efficacy, there are a plenty of case studies. There is plenty of anecdotal evidence and studies showed the benefits to the patients by using this therapy. If your CP child failed the conventional treatments, you might consider consulting a trained homeopathic practitioner.

### **2.11 Pet therapy**

Pet therapy, or animal-assisted therapy, is a complementary therapy for CP children to obtain a lot of benefits from PT and other types of treatment. Working with animals can help CP children reach their goals when added to classic therapies. It is of great importance to work with therapists and animals that are trained and licensed and have experience working with CP children. Pet therapy is the use of well-trained animals to promote wellness, boost mood, and help therapy, and other broad uses in mental and physical health care [30]. There are different ways of pet therapy, either informal or formal. When a trained dog visits a nursing home or hospital to cheer up residents and patients, it is informal. On the other hand, when the animal is the central aid or participant in a guided therapy session, it is formal. Dogs are frequently used in pet therapy but other kinds of animals like cats, horses, and even guinea pigs can be involved.

#### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

A study published by the U.S. National Institutes of Health showed that "personal and social benefits gained by dog-assisted therapy may aid in the prevention, improvement, and development of children with various disabilities" [31]. Pet therapy has been used in different situations such as chemotherapy sessions, dental work, and other potentially scary or stressful procedures for children, or even adults, PT sessions to treat injury or a stroke, mental health problems, or for residents in longterm care facilities. It is also commonly used to assist CP children with disabilities.

There are documented benefits of working with animals with special needs of children and adults in formal and informal settings. In mental health cases, being around animals and interacting with them have been shown to lower anxiety, increase relaxation, reduce loneliness, provide comfort, and increase mental stimulation [32]. Physical benefits of working with animals have been well documented, including lowering blood pressure and heart rate, improving cardiovascular health, and reducing pain. Petting and playing with animals have been shown to increase serotonin and reduce cortisol, which together promote less stress in the body.

Having an animal in the PT session for CP children can provide numerous benefits like working with animals during PT helps children reach specific goals, sessions will be less stressful, and children are more engaged and enthusiastic about doing the work. Animals provide good physical support to the children to do their exercises, children prefer using animals than an object for support, and animals motivate children to work harder, meet their goals, and return for subsequent sessions. CP children usually have a lot of mental health issues and behavioral challenges such as ADHD, depression, and anxiety as comorbid conditions. Animals can help improve children's mood, reduce anxiety, and reduce stress. Benefits of behavioral therapy sessions using animals are motivation, support, encouragement, and someone to bond with and help a child be more engaged and enthusiastic about treatment [33].

One study established a goal for disabled CP children therapy using trained dogs to assist. Results have shown that before therapy children were unable to complete the therapy sessions, but all completed the animal sessions and met their goals after therapy. The animals helped them break down resistance and fear and to carry on with successful therapy sessions.

Children showed improvement in their communication and became better able to tell others what they need or want. They became more sympathetic from working with dogs and they became better able to ask for help and provide help to others. Also, their social skills have improved. Dogs are the most used animals because of how easy they are to be trained and their love of people, but other animals can be trained to work with children with special needs as well. Equine therapy and dolphin therapy have been used as well. Equine therapy may include riding, petting, or caring for horses. The outcome of the sessions relay on the child's goals but working with horses has the added benefits of getting children outside and improving self-confidence. There are additional potential benefits from the dolphin therapy beside the obtained benefits from other kinds of animals, but it is not common. CP children with mobility issues and pain can be easier to work in the water. However, dolphin therapy is relatively new, and there is little available evidence that it helps. This therapy is expensive but there is an increase in the number of facilities offering this therapy. You should work only with a trained and licensed therapist.

Informal therapy can help CP children who may have to spend time in the hospital for treatments, surgery, and for recovery after surgery by making them more relaxed in a stressful environment. They provide comfort, reduce anxiety, make the hospital setting feel more like home, and offer a feeling of love and acceptance for children

who are struggling. Also, children can communicate with and relate better to doctors and nurses. Pet therapy can be a great way for CP children and other disabilities to get more out of their therapy sessions **3.1.**

### **2.12 Pilates**

A fully integrated program of exercises using special apparatus, amid to improve physical strength, flexibility, posture, endurance, and mental awareness. It is easy to be used for beginners, they can use it because it does not require heavy weights or strenuous cardiovascular work, it is easy on the joints, and it has many health and fitness benefits. It can be used by all ability levels and can provide a significant strength workout for advanced athletes or a gentler workout for beginners, patients recovering from injury, or those with physical limitations. For CP children and adults, exercise of any type may seem daunting. Physical activity and supervised exercise have many benefits for CP patients as well as healthy people. Pilates is a suitable program to be adopted by people with physical limitations and to improve the CP symptoms while also increasing mobility and range of motion.

Pilates became very popular in the modern area, but it is nearly 100 years old, and it was created by Joseph Pilates in the 1920s. It involves the use of low-impact movements that focus on muscle strength, flexibility, and endurance [33]. Good posture and spinal alignment, balance between muscles, and core strength are the focus. Many moves can be done without equipment, but Pilates machines are used to help do specific movements and exercises.

Physical activity of any type is beneficial for everyone. If workouts routine is created to match an individual's ability level and limitations, any type of exercise improves cardiovascular health, muscle strength, bone density, and other areas of the body and mind. Great health benefits can be obtained by Pilates, such as greater flexibility, improved balance and posture, reduced back pain, greater strength and stability in the core, improved overall muscle strength, greater muscle endurance, and better mental well-being.

Symptoms of adults and children can be improved by practicing Pilates, but other specific benefits are to be achieved. A child may have trouble to control his muscle movements, and he/she might be able to bend or straighten his/her leg but nothing in between. Guided work on a reformer (Pilates equipment with a sliding frame) could help children develop greater control over their movements. Those exercises can be done while the child is lying down, often in a more comfortable position.

Targeting children's trunks with physical and strength training could significantly improve mobility and balance, a study showed. Children, before the study started, were not able to sit up by themselves. They were trained using specialized equipment used to target their trunk muscles and hip joints. After several weeks of training, they were better able to control movements and could sit and balance independently. The study did not use Pilates movements, but other studies have demonstrated that Pilates training can improve strength and posture stability in the trunk. Children who used Pilates have the chance to improve their stability, so they are able to sit up much easier, be more stable and balanced, and have greater control over their movements.

There is plenty of anecdotal evidence from personal stories that practicing Pilates can benefit adults and children with physical limitations. Gaining greater strength, posture, and balance between muscles that were previously weaker or stronger than others was described by adults. Stories of children who used Pilates movements in their PT sessions made them more independent, have greater joint range of motion, and

#### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

have greater muscle strength that was once weak and difficult to control. The improvements in strength, balance, flexibility, and posture all help reduce pain as well [34].

Emotional and mental benefits of using Pilates can be experienced by children. The improvements in a child's pain and movement using Pilates could be great, and they give a great sense of control, achievement, and even relaxation with less stress. A positive body image can be achieved in all types of people, better with and without disabilities by using Pilates. It is recommended to try Pilates under the supervision of a trained instructor. The movements are generally easy, but it is easy to be done incorrectly. Most of the poses and movements are very specific and it could be of benefit if supervised by a trainer to correct and guide them, especially in CP children. Hospitals, medical centers, and physical therapy centers offer in-house Pilates classes and other types of exercises, so start with your medical team to find out how you can safely get started with Pilates.

#### **2.13 Yoga**

Yoga is an ancient practice of mixing physical with spiritual elements. Despite it being old Indian practice, nowadays it became more popular than ever. Stress relief, flexibility, strength, and other health improvements can be achieved by practicing Yoga. It can also be of great help to CP children and adults.

There are few clinical studies on yoga's effect on CP children. However, benefits were greatly documented from individual stories, anecdotes, and case studies showing Yoga, specially modified for personal needs, can have a positive effect on CP patients' life quality. While some studies for CP children are inconclusive [35], but evidence that yoga provides health benefits, in general, has been documented. There are different branches of complete yoga practice, like breathing exercises and meditation, but recent practitioners focus on asana, the postures.

Asanas are specific positions that are held for sometimes and that are designed to prepare the body with strength and clarity for meditation. On the one hand, Asanas had classic and original purposes; in recent practice, they provide several physical and mental health benefits. On the other hand, hatha yoga is a series of poses that are held for a period of time with a focus on breathing.

Benefits such as weight loss and better eating habits have been shown in studies of people practicing yoga [36]. Ashtanga and Power Yoga are intense and strenuous, but other forms of Yoga are not. Stimulating metabolism while helping with weight loss and weight management can be achieved by practicing Yoga.

The mindfulness practiced during yoga also helps people eat more mindfully, eating smaller portions, and making better choices. Overall better physical fitness, improved cardiovascular health, and lower blood pressure are proven benefits of Yoga. Yoga like PT improves muscle strength, balance, gain mobility in CP children often modified for a person's needs, or limitations to help children see benefits. Yoga stretches the body and enhances flexibility, joints range of motion, and over mobility. Yoga especially can stretch the spine and help realign it better [37]. Spine stretching increases the spaces between vertebrae, which in turn decreases pressure on nerves. Less muscular tension and relaxation throughout the whole body is the overall result. Other less tangible benefits for CP children include relaxation, less stress, better body image, and an overall better sense of well-being.

Health care providers should consider Yoga as part of CP children and adults' treatment plans. Asana postures are not possible to be done as they are described in patients with any degree of physical disability. Only, they must be adapted for patient with a disability to see benefits. Chair yoga is a perfect example of adapted Yoga in CP patients allowing them to enjoy the benefits of Yoga while they are confined to a wheelchair. The positions are modified from the perspective of sitting in a chair like a child with a balance problem can still use a pose, but while sitting. Other yoga adaptations involve different other props, such as blocks or straps, and the help of a trained practitioner or coach who has experience working with disabled patients.

Asanas are the most common yoga type in the west, mindfulness is the most important part of this ancient practice. Yoga users must be mindful by focusing on the body's posture and breathing while performing the poses, active practice of meditation by sitting still and focusing on the present, most often by focusing on breathing while you are practicing yoga. Meditation can benefit CP children and adults by lowering stress and anxiety, reducing gastrointestinal symptoms, improving sleep, and reducing feelings of depression.

Trying yoga is a good way to see real and positive benefits in CP children. It is very important to work with a professional who is trained in instructing yoga positions and can work with people who have physical disabilities. The poses will need to be adapted and it takes an experienced professional to know how to adapt them to everyone. Despite yoga being an old practice, but nowadays it has been modified and adapted in ways that are varied and positive. Yoga can help CP children to be able to participate in an activity that helps them move better, feel better, and have a greater sense of self-confidence and control. The many benefits of yoga are why every child should give it a try**.**

### **2.14 Functional electrical stimulation**

It is developed initially to use electrical pulses to stimulate muscles in patients suffering from paralysis. Functional electrical stimulation (FES) currently treating different disorders like CP. It has been tested in clinical trials, and it has been tested for different disorders such as stroke, multiple sclerosis, and CP. In CP children, it is shown to improve range of motion, muscle mass and strength, walking speed, spasticity, gait, and foot and ankle positioning. Still, more research is needed for CP children and other neuromuscular disorders.

FES is a simple technology of a small device that delivers an electrical impulse to a muscle. It is a low-energy current that acts like a tiny shock to activate nerves, which in turn causes the muscle to move [38]. It has been used in paralyzed muscles in a person after an accident who cannot move them. It helps a person with smallscale muscle movements like voiding the bladder and swallowing, as well as with larger movements such as walking, grasping objects, or standing up. Also, it has been used after stroke in a person who has lost some muscle function, and for those with neurological disorders or head injuries. The procedure is safe and not painful because the electrical energy delivered is low. The electrical impulse may cause a little tingling or, sometimes, a slight burning sensation. It is not considered as a lifelong mobility aid, but it is a functional treatment restoring function. Usually, its use is for a shortterm to help retrain muscles and restore some degree of voluntary muscle function. Implanted electrical stimulation devices are a new technology helping paralyzed patients to restore some muscle movement.

Spastic CP is very common and accounts for about 70 and 80 percent of all children with CP [39]. Children have painful stiff muscles, and their reflexes are exaggerated. Spastic CP children have different degrees of trouble walking. Commonly, they have involuntary limb movement, continuous muscle spasms, joint contractures, and limited flexibility. Some studies demonstrated that spastic CP children have a

#### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

better and easy walk by applying FES. In one study 32 children, with an average age of 10 years, received eight weeks of daily functional electrical stimulation to the muscles [40]. There were two groups, an FES group and a control group. Evaluation schedule was at the beginning of the study, eight weeks of treatment, and then six weeks after that. The study has an end point of assessing the children's ability to walk and their own perceptions of how they walked before. FES group children showed great improvements in how they perceived their ability to walk. They felt that they are walking better and with less pain.

In a hemiplegic spastic CP children study, FES improves gait abnormalities [41]. The children in the study were able to walk using braces. FES has replaced children's braces or splints. Evaluation was done before and after the treatment, toe-walking and other asymmetries were improved greatly, and all children were able to walk more symmetrically.

Foot drop; There is a common problem in CP children, they have trouble picking up their feet to take steps, and their toes drag while they are walking. They can overcome this by lifting their knee up higher or swinging it outward to be able to elevate the foot off the floor while walking. This can cause pain and other issues later by doing this awkward movement to keep the foot from dragging. Braces or orthotics can correct the foot drop at the expense of the child's movement limitation. On the other hand, FES shows great promise to treat foot drop in CP children. FES device was used in a group of children for 4 months, and they have gait evaluations periodically. They had no change in the speed of their walk, but there was improvement in their ankle flexion and foot with reduced awkward movements to avoid dragging the toes.

Despite the positive study results of using FES in CP children, still it is not accepted as a common treatment. Currently, enrolling in clinical trials is the only way to get the treatment. Using FES can give a child hope to move free from awkwardness and pain. While the treatment is not widely available, its apparent effectiveness and safety mean that its use will likely become more widespread.

#### **2.15 Chemo-denervation**

Chemo-denervation such as using botulinum toxin type A has proved easier, more effective, and less painful for patients. First clinically introduced in the United States in the early 1980s, botulinum toxin is a potent neurotoxin derived from the anaerobic bacteria *Clostridium botulinum*, but when used in treatment, no serious systemic toxin effects have been reported [42].

The medication is more costly than alcohol or phenol, but the cost is offset by less physician time and the lack of anesthesia. The formation of antibodies has been a concern, but this can be prevented by allowing 2 months to 3 months between injections. Botulinum toxin works by acting in the neuromuscular junction, preventing the release of acetylcholine, which results in functional denervation. It can be given without EMG and anesthesia, does not cause dysesthesias, and is no more painful than an injection of saline solution. Effects are local and last 3 months to 4 months or longer. It is contraindicated during pregnancy, lactation, in individuals with neuromuscular disorders (such as myasthenia gravis), in patients taking aminoglycosides, or in those who have a known allergy to the drug. Adverse effects are not common and are usually associated with the site of injection, such as bleeding, bruising, soreness or redness at the injection site, or diffusion to nearby muscle groups. In patients that do not respond to botulinum toxin, possible reasons should be considered before labeling the patient as unresponsive. Reasons could be related to injection technique, improper toxin

storage, or the patient's individual characteristics. Overall, botulinum toxin has proven clinically to be effective, safe, and less painful than other invasive therapies [43].

Botulinum toxin is available in serotypes A and B, which have different unit potencies, side-effect profiles, and dilution schedules. Both have been used in children with cerebral palsy, although serotype A has been used more extensively. Dosing guidelines have been suggested for botulinum toxin A for adult and pediatric patients. Adult recommendations are available for botulinum toxin B, but studies are ongoing for pediatric patients [44].

Some results suggest that botulinum toxin type A can be effective in reducing muscle tone over a longer period, but not in preventing development of contractures in spastic muscles. Mechanical and functional alterations can arise from the muscle tissue itself even though the nervous system is the site of the primary lesion. The gross mechanical changes occur in skeletal muscle secondary to spasticity and during development of contracture. Muscle stiffness can change for a variety of structural reasons, only one of which is altered fiber length. There is currently no evidence in the literature that muscle fiber length is shortened in contracture or in spastic skeletal muscle. Contracture formation results from inappropriate architectural adaptation of extremity muscles in response to upper motor neuron lesion [45].

Several studies have reported the successful use of botulinum toxin A for the treatment of drooling in children with cerebral palsy, using injection into the submandibular or parotid glands alone or in combination with other agents. In some studies, the beneficial effects have lasted for up to 4 months without serious side effects or disturbances of oral function [46].

Other treatments include *chemical neurolysis*, in which the nerve conduction is impaired using chemical agents and therapeutic nerve block using phenol or alcohol. The goals of these treatments are to prevent muscle contractures and improve the patient's function. A common side effect is that after the nerve is injected, alcohol levels measure above the legal limit in children. Other side effects include damage to sensory and motor nerves, pain at injection site, scarring, and dysesthesias. To ensure the correct site, an injection must be made using an electrical stimulator [47].

#### **2.16 Neurosurgical approaches**

Another treatment used to alleviate spasticity in children with cerebral palsy is *rhizotomy.* Studies have shown that performing selective dorsal rhizotomy at a young age can reduce the need for orthopedic surgery [48]. Goals of rhizotomy are decreased tone, increased mobility, and the facilitation of care for the patient; however, the reduction in spasticity cannot be predicted and sometimes results in excessive hypotonia [49]. The procedure is very meticulous, requiring general anesthesia and a neurophysiologist who must be present to identify which nerve is to be severed.

Other *neurosurgical approaches* include peripheral neurectomy, myelotomy, and dorsal column electrical stimulation.

It has been established that oral baclofen does not cross the blood-brain barrier effectively and that higher doses of the medication result in serious side effects. Intrathecal baclofen results in a greater decrease in spasticity by allowing higher concentrations of baclofen in the cerebrospinal fluid at about 1% of the daily oral dosage [50].

To be considered for intrathecal baclofen pump placement, the patient must have severe lower limb spasticity that does not respond to other less-invasive treatments. The patient must first be given a trial of 50 μg baclofen through a lumbar puncture or spinal catheter. If unresponsive, 75 μg can be tried after 24 hours and a third trial of

### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

100 μg can be tried 24 hours after that, after which if the patient is still unresponsive, he or she must be excluded from the treatment [51]. Implantation lasts 1–2 hours, and the pump is easy to refill subcutaneously. It is programmed by a computer-controlled radiotelemetry programmer that is linked to the pump's internal computer and selects the rate and pattern of baclofen administration. Complications to intrathecal baclofen include hypersensitivity to baclofen, intolerance to the side effects of baclofen including drug tolerance, cerebrospinal fluid leakage, pump pocket seroma, hematoma, infection, and soft tissue erosion. The objective of intrathecal baclofen is to individualize the patient's dose and infusion so that the lowest dose that yields the greatest response can be achieved [52]. In comparison, intrathecal baclofen has less complications and side effects than other treatments and more generalized results in both cerebral and spinal spasticity, making intrathecal baclofen the most effective current tool for the treatment of spasticity in non-ambulant individuals. A recent systematic review showed that there was no evidence to support the clinical use of intrathecal baclofen in ambulant individuals with hypertonicity without further rigorous longitudinal studies [17]. As a precaution, families are prescribed diazepam or diazepam rectal as well as oral baclofen to have at home. If there is evidence of withdrawal, one of these medications is administered, and the patient is instructed to go immediately to the emergency department. Although aggressive use of benzodiazepines and oral baclofen may be helpful, recognition, and return to appropriate intrathecal baclofen dosage are essential for rapid recovery [53].
