**2.3 Oral medications**

Oral medications have been used to decrease spasticity; however, they have a lot of side effects such as drowsiness, sedation, confusion, and fatigue. Benzodiazepines, like diazepam, are rarely used because of their strong sedating effects. They result in enhanced presynaptic inhibition, but because they are presumed to enhance the postsynaptic effects of GABA, they can only work if the GABA-mediated process functions. Benzodiazepines have a long half-life and an active metabolite. Benzodiazepine therapy is indicated in spinal cord injury and multiple sclerosis with possible application in traumatic brain injury, cerebral palsy, and cerebrovascular accident. Clinical effects include sedation and reduced anxiety, decreased resistance to passive range of motion, decreased hyperreflexia, and reduction in painful spasms. Side effects of all benzodiazepines include sedation, weakness, hypotension, gastrointestinal symptoms, memory impairment, incoordination, confusion, depression, and ataxia. Also, benzodiazepines are controlled substances with the potential for dependency. Diazepam is the most widely used benzodiazepine for spasticity management. The recommended initial dose is 2 mg 3 times daily with a maximum dose of 60 mg daily (20 mg 3 times daily). If nocturnal spasticity is the presenting problem, the patient should be started with a single dose at night.

Like benzodiazepines, baclofen works centrally. Baclofen binds with GABA-B receptors on brain and spinal membranes, restricting calcium influx into presynaptic nerve terminals, thereby reducing spasticity. The use of baclofen is indicated when spasticity is of spinal origin. The clinical effects include decreased resistance to passive range of motion, decrease in hyperreflexia, and reduction in painful spasms and clonus. Unlike benzodiazepines and baclofen, dantrolene sodium works peripherally at the level of the muscle fiber. It has no effect on neuromuscular transmission, but works by acting directly on the skeletal muscle, hindering the release of calcium from the sarcoplasmic reticulum, thereby preventing the excitation-contraction coupling

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

mechanism. This affects both intrafusal and extrafusal fibers by decreasing the force of muscle contraction. However, this mechanism is not selective for muscles with increased tone, and the resulting generalized muscle weakness may weaken respiratory muscles. The use of dantrolene sodium is indicated in treating spasticity secondary to cerebrovascular accident and cerebral palsy, and has possible applications for traumatic brain injury, spinal cord injury, and multiple sclerosis. Clinical effects of dantrolene sodium include decreased resistance to passive range of motion, decrease in hyperreflexia and tone, and reduction in spasms and clonus. Another group of oral medications used in spasticity management includes clonidine and tizanidine, which are alpha 2 noradrenergic receptor agonists that release excitatory neurotransmitters and inhibit supraspinal facilitatory pathways [5].

Tizanidine is a new oral anti-spasticity agent that is selective in decreasing tone and spasm frequency in only spastic muscles, eliminating the unwanted side effect of generalized muscle weakness. Tizanidine is reported to have reduced symptoms of spasticity in patients with multiple sclerosis or spinal cord injury and is well tolerated in most patients. It is an imidazoline derivative like clonidine but without the cardiovascular effects when appropriately titrated. Tizanidine results in a direct reduction of excitatory amino acid release from spinal interneurons and inhibits facilitatory cerebrospinal pathways. Its peak effect occurs 1–2 hours following administration and its half-life is 2.5 hours. The clinical effects of tizanidine include reduced muscle tone, spasm frequency, and hyperreflexia. Animal studies with tizanidine demonstrate antinociceptive activity under specific conditions with increased dose titration [6].

As with other anti-spasticity medications, the potential side effects of tizanidine are dose-related and may be mitigated by dosage titration. The potential side effects include drowsiness, dry mouth, and dizziness. Literature suggests that tizanidine may be better tolerated than other anti-spasticity agents as measured by the global tolerance rating scale. In placebo-controlled studies, tizanidine has been shown to be effective in multiple sclerosis and spinal cord injury. It is also useful for spasticity of spinal pathology when weakness is of concern. Tizanidine may also prove effective in managing spasticity of cerebral origin.

Secondary oral and systemic agents include tiagabine, cyproheptadine, clonidine, lamotrigine, gabapentin, and carbidopa-levodopa [7]. Multiple medications have been recommended, of which the most recent addition is gabapentin.

The use of antihypertensive pharmacologic agents in treating spasticity is unclear because randomized trials have not been performed. Nifedipine has been used in a bit-and-swallow technique; more recently, captopril also has been found to be of benefit [8].

Anticholinergic medications are used in CP patients for different issues, such as uncontrollable limb and facial movements, muscle spasms, tremors, and excessive drooling. Anticholinergics block the area of the brain that causes muscle movement [9], which in turn helps to control many of the most common symptoms in CP children. Small doses of anticholinergic medications could be beneficial in some children, whereas other children will require higher dosages. The most common anticholinergics used in CP children include Robinul, Sinemet, benztropine mesylate, and trihexyphenidyl hydrochloride.

Antidepressant medications have been used to improve moods and enhance well-being. These types of drugs are not for everyone, and they have been used in children with depression, anxiety, and other mental and emotional problems that can come from living with a debilitating disorder. Antidepressants are generally used in combination with behavioral therapy [10]. Different antidepressants could be

used, but the most commonly have been used are Celexa, Paxil, Prozac, Cymbalta, Lexapro, and Zoloft. Its side effects may differ from patient to patient. Different pain medications have been used, and the most commonly used ones are to control pain by reducing inflammation. Some CP children will experience chronic, long-term pain and anti-inflammatory medicine can be prescribed to relieve their pain. The most common types of anti-inflammatories prescribed to CP patients include nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids. Some parents would rather use natural medications as opposed to traditional drugs, whereas others may try alternatives when the first line of prescribed medications fails to relieve symptoms. Others use a combination of complementary and alternative with conventional medicines. Complementary and alternative medications generally include biologically based supplements, homeopathic medicines, and herbal medicines.

### **2.4 Speech therapy**

Health care providers will recommend speech therapy if the child has communication, swallowing, and breathing issues. Speech therapy provides a wide range of exercises to help children better communicate, address, and help in other disorders affecting speech. A child might have mild to severe speech impairment. However, a study from the National Institute of Neurological Disorders and Stroke (NIH) stated that despite not every CP child had speech impairment, many CP children had some form of speech impairment [11]. A licensed speech therapist evaluates every child to create the optimal individualized plan to help children have better communication. They provide exercises that help children understand gestures, words, numbers, sounds, and more. Also, they help with common problems for CP children such as breathing, swallowing, and digestion issues. They use a variety of exercises such as sign language, communication through writing and painting, winking, voice synthesizers, picture boards, and using augmentative communication devices. Theos' exercises will improve disorders such as pronunciation skills, vocabulary, development, listening skills, comprehension and formation of words, fluency, direct conversation engagement, and mouth and throat issues. The speech therapist will evaluate every child fully to come up with an individualized based on the child's needs. Dysphagia is a very common problem in CP children, which is secondary to physiological and neurological disorders, as well as irregularities in the throat. Choking on food and drinks, breathing difficulties, excessive coughing, and pulmonary aspiration of food and fluids must be addressed. Other associated conditions such as stuttering, dysphagia, aphasia, dyspraxia, intonation and rhythm issues, vocal tract problems, and dysarthria must be addressed too. Prevention and reduction ofother associated disorders such as easily choking on foods/liquids, extreme coughing, pulmonary aspiration, difficulties with breathing and dehydration, and malnutrition (typically because of choking on foods/liquids) also have to be one of the therapist's goals.

Communication is an important human experience, it shapes people's personalities. Children with communication issues are already at a disadvantage. Proper speech therapy helps the child to overcome their problems and let them communicate better. It will provide the child with the proper ways of communication and help him/ her throughout the course of life, including daily living and social activities [12]. It provides other benefits such as learning, the ability to participate fully in school and home activities, better relationship development with friends, peers, and family, better socialization skills, and the ability to communicate ideas consistently and effectively. A master's degree in speech and language pathology is required to be a speech

therapist/speech pathologist, and most states require that they get certified through the American Speech-Language-Hearing Association (ASHA). To obtain ASHA certification, speech pathologists must complete numerous courses dealing with the throat, mouth, speech, psychology, social work, and more [13].

## **2.5 Massage therapy**

CP children can gain mental, emotional, and physical benefits from massage therapy. Massage therapy must be approved by the child's doctor before starting such a program. Massage therapy supports the treatment of body's connective tissues and muscles are massaged and stimulated through direct contact by a massage therapist to help healing and well-being of the patient. Direct hand pressure by the therapist will be applied to different body parts. The pressure could be light to heavy, depending on which body part is being stimulated. Therapists can use different types of massage techniques, which are more than 180 techniques with their hands, elbows, arms, and more.

Although the National Institutes of Health (NIH) states that more research is needed before recommending massage therapy to every CP child [14], the American Therapy Massage Association (AMTA) states that anyone can benefit from massage [15]. A published study by the University of Washington and Seattle Children's Hospital, and Integrative Touch for Kids, showed lessening of painful symptoms by using massage therapy. The study stated, "It is well documented that massage increases blood flow to the tissues and that enhanced blood flow encourages growth of new tissue and healing of wounds" [16].

Massage could stimulate the brain's pressure receptors when the cranium is massaged and stimulated, it gives a sense of calmness and in return, and the child will be able to focus and concentrate better. Fine and gross motor functioning improves when muscles are relaxed and less rigid. This helps all aspects of CP children's lives, including playing, socializing, learning, and carrying out daily tasks. Circulation and digestion issues are very common in the CP children. Immobility is the reason for circulation problems; on the other hand, the central and peripheral nervous system structural abnormalities might lead to digestion issues. Relieve tension in the abdominal muscles can help to improve digestion by reducing gassiness and bloating, stimulating peristalsis leading to better digestion, aiding in the release of digestive enzymes, and stimulating kidney and liver activity.

Improving sleep in CP children and adults can be achieved by massage therapy. According to the American Massage Therapy Association (AMTA) and a study published by the National Institutes of Health (NIH), massaging has an essential role in the quality of CP children's sleep (American Massage Therapy Association | AMTA) [17]".

Skin, exocrine glands, hair, and nails are the integumentary system of the body's organ that acts as the first line of defense against outside factors. Skin infections and other integumentary system problems are common in CP children because they cannot care for themselves. This system can be protected by stimulating the skin, improving skin tone and texture, assisting in body temperature regulation, promoting tissue repair, moisturizing skin, removing dead skin, and stimulating sensory receptors.

Massage therapy can be done in physical therapy centers, private massage therapy clinics, hospitals, chiropractic centers, athletic clubs and sports centers, spas, at home, and health clinics. Although massage therapy has shown many benefits, in some instances, it is not advisable. Message therapy is not recommended if the child has muscle and/or joint inflammation, fever, acute infections, skin disorders, open

sores, swollen lymph nodes, vaccinations within the past 72 hours, blood clots, diarrhea, osteoporosis, and varicose veins.

Massage therapists cannot give any medical advice regarding your child's disorder or any other medical issue, psychological counseling, diet or nutrition counseling, touch private parts of the child's body, perform any type of surgery, and provide skin or cosmetology services. Usually, massage therapy sessions are not covered by insurance, and you might have to pay out-of-pocket expenses.

#### **2.6 Hippotherapy**

Hippotherapy is using horses and equine equipment to help CP children to develop better physical, emotional, and neurological functioning. Health care providers usually recommend classical and traditional therapies such as PT and OT, which help to strengthen muscles, improve balance and flexibility, and help with everyday living tasks. On the other hand, hippotherapy can help CP children greatly. It started overseas in the sixties, but it came to the United States after the great benefits it produces. Cognitive ability, neuromuscular problems, physical strength, and a heightened sense of well-being can be improved by hippotherapy [18]. A horse's movements can be channeled by using equine equipment. Hippotherapy and therapeutic horseback riding are two different therapy modalities to gain different benefits. The gait, rhythm, repetition, and tempo of a horse's movements have been proven to help with: balance, posture, strength, control, visual cues, sensory, endurance, abnormal muscle tone, social skills, control of the body's extremities, core strength in the trunk, and self-esteem.

After the health care provider ensures that child mental and physical challenges could benefit from this form of therapy, he/she can recommend hippotherapy. Also, the health care provider and the therapist must agree that the child's associated disorders will not be affected negatively by the physical challenges of hippotherapy. Hippotherapy can started at any age and has no age limit. Insurance companies usually do not cover the therapy, and you may pay out of pocket for it. A full evaluation of the child's physical, emotional, and cognitive strength must be done by the therapist to determine if the child is ready for hippotherapy and if any modifications must be provided for the child while sitting on the horse. Safety issues, including how to correctly mount and dismount the horse (with assistance), horse equipment, and what to expect when the horse moves, must be explained by the therapist. After safety training is in place, assisting and monitoring the child during mounting the horse and during the horse's movements, and walking alongside the horse and child while helping modify the horse's movements must be done by the therapist to make sure the child is safe. Hippotherapy will help to build physical strength and endurance and improve the child's well-being and sense of self. The sessions usually take place in horse farms created as specialized training areas. Physical therapists, speech therapists, or occupational therapists can provide the therapy sessions. They must go through extensive hippotherapy training (at least 3 years of their own field of study and 100 hours of hippotherapy training) and have their own certifications. Therapists need to have the following: They must learn in-depth knowledge of horse movement, how to handle emergencies, safety practices, the physical characteristics of horses, the association between human and horse movement and how to choose the appropriate exercises for each child's individual needs, and more. If the child's doctor approved the therapy, the therapist has ruled out any conditions that would prevent participation by the therapist.

## **2.7 Aquatic therapy**

Aqua therapy or aquatic therapy is a group of water-based exercises improving a person's physical abilities and functions. The medical community recommended it as a way to help heal the body [19]. Aquatic therapy has shown improvement in CP children because by allowing them to move freely without putting stress or much weight on their bodies. Water is known to reduce weight by 90%.

Aquatic therapists help CP children to develop more muscle control, increase self-confidence, improve strength and physical function, and gain more life independence. The therapy itself has many physical and mental benefits to CP children. Physical benefits include improved heart function, increased resistance, relief and reduced pain in the joints and muscles, help in protecting against injuries, and reduced discomfort while exercising, help in building muscle and muscle control and better circulation, and improved endurance and flexibility. Mental and emotional benefits include improved confidence, better quality of life, strengthened socialization skills, improved sensory integration, and improved sense of independence.

The severity of the child's disorder, age, physical fitness level, and any associated illnesses or disorders will determine the best therapy program for the child. Popular aqua therapy exercises include swimming (at all levels, including learning to swim), aquatic yoga, water-based range of motion exercises, balance exercises *via* flotation devices in deep water, breath control exercises, assisted walking exercises, deep-water walk, and social games to help improve social interaction, eye contact, and sportsmanship. Flotation devices, toys, weights, compression vests, and balls are different equipment used during the aqua therapy session.

Children's safety is of utmost importance during the aqua sessions. In turn, most pools are generally smaller than standard-size pools and come with fiberglass or stainless-steel shells, built-in attached equipment, safety rails and ladders, thermostat to warm water, and easy-to-grip edges. An active AEA Aquatic Fitness Professional Certification (AFPC) is a requirement for any physical or occupational therapist to carry out the sessions. The session lasts 30 to 45 minutes depending on the child's individual needs. Kids must bring swimsuits, towels, and water shoes to each session. Some classes may provide these items depending on the program and the family's financial status.

### **2.8 Osteopathic manipulation**

A trained osteopathic doctor (DO) can provide osteopathic manipulation therapy (OMT) by applying a gentle manipulation of the musculoskeletal system to relieve symptoms and improve overall wellness in patients. The philosophy used by DOs is a holistic, preventative approach with a focus on the musculoskeletal system, how it is linked to disease, and how it can be manipulated for treatment. Despite there being some evidence that OMT can help CP children move better and feel better, the studies are small and have mixed results on how OMT can help those children.

OMT is based on the notion that all body systems are connected, and this connection affects disease and wellness [20]. Osteopathic manipulation therapy is based on a hands-on approach, which is an important part of OMT. DOs use stretching and gentle pressure to manipulate joints and muscles. Musculoskeletal disorders such as back and neck pain or sports-related injuries are common examples of OMT. Some DOs use the technique for different types of conditions, citing a healing touch as crucial to wellness.

OMT has been used as an alternative therapy for CP children complaining of musculoskeletal system symptoms. It is a complementary therapy to more traditional therapies such as PT, OT, surgery, and pain medication to relieve symptoms and pain, improve mobility and reduce spasticity, and more. Cranial osteopathy can be applied to the head and neck. It is a subtle gentle manipulation of the skull that can be used in babies but that can also be used in children and adults.

OMT was studied to see its usefulness in 55 spastic CP children (moderate to severe spasticity) between 20 months and 12 years of age [21]. There were three groups: a control group with no treatment, a group that received acupuncture, and a group that received cranial osteopathic manipulation along with myofascial release. Eleven outcomes were listed as outcomes. The acupuncture group had no significant positive outcomes; on the other hand, the cranial osteopathy group had a positive outcome in two measures (total Gross Motor Function Measurement and the mobility part of the Functional Independence Measure for Children) in comparison with the control group. In another study, thirteen children diagnosed with both cerebral palsy and chronic constipation were studied using OMT. Children were divided into two groups; one group received OMT, while the other group received OMT and traditional medical treatment for constipation. At the conclusion of the study, both groups had equally positive benefits and improvements in constipation [22].

A larger recent study of the use of cranial manipulation in CP children has cast doubt over the treatment's effectiveness. A British study for 6 months of 142 children using cranial osteopathy. There were two equal numbers of children in each group, and one group received the treatment, while the second group was placed in a control group. The children's movement was evaluated after 6 months, and there were no statistically significant improvements as compared to the children from the control group [23]. Children's parents in the treatment group felt that their children had positive gains, in comparison with only a few parents in the control group. Reported positive results by the parents were better sleep, better use of arms and legs, and improved mood [24]. It is not clear if OMT may or may not help CP children, it is different from child to child how it helps. If the therapy is administered by a licensed DO, there is almost no risk of side effects or complications with this type of therapy.
