Medications for Cerebral Palsy
A wide assortment of medications for cerebral palsy is used to reduce symptoms and complications. Children who experience seizures, spasticity, and unwanted or uncontrolled movements, such as athetosis and chorea, for example, are often prescribed drugs to minimize the movements. Some medications are used to relax muscles, increase comfort and facilitate better posture.
Medication is often prescribed to improve associated conditions, as well. Many drugs will aid digestive problems, breathing difficulties, skin conditions, and behavioral or learning issues.
When choosing prescriptions, doctors and parents consider the benefits as well as the short- and long-term side effects. Many drugs used to treat cerebral palsy are very powerful, and some are not recommended for children. Some doctors may avoid prescribing certain medications to children because of the potential impact on the child’s growth and development.
Drug manufacturers change, new medications are developed, industry regulations fluctuate and insurance coverage is modified annually.
Despite extensive knowledge of the medical field and pharmaceutical industry, it is often a process of trial and error for a doctor to determine which drug will work best – and in what dosage – for any given child. Even when success is achieved, some medications must be regularly monitored and adjusted.
Certain medications are designed to target specific conditions, such as seizures, but that medication may be available in several different forms. Since every person has his or her own unique chemistry, a medication that works well for one child may have adverse effects on another. Some children may acquire tolerance of some medications and require an adjustment in dosage.
All changes in conditions, symptoms or treatment should be shared with the primary care physician to ensure drug therapy is properly prescribed.
The most common medications used to treat cerebral palsy include medications within these categories:
Anticholinergics (Uncontrolled Body Movements)
Anticholinergic medications are used to treat uncontrolled body movements such as muscle stiffness, tremors and spasms, as well as drooling associated with non-spastic cerebral palsy. The result of the medication is temporary. In large doses, some anticholinergics can stimulate the nervous system; in small doses the drug can act as a depressant.
Common uses include treating spastic conditions in the digestive tract, reducing saliva, and decreasing bronchial secretions. Some forms of cerebral palsy where anticholinergics may also be prescribed include:
- Athetosis – slow, writhing movements that are often repetitive and involuntary
- Chorea – jerky, involuntary, irregular and uncontrollable movements
- Choreoathetoid – a combination of chorea and athetosis, where movements are jerky, twitching, slow and writhing
- Dystonia – prolonged, involuntary contractions that result in twisting motions, tremors and abnormal posture
These drugs work by blocking the neurotransmitter that causes muscles to move. Excessive movement is often caused by excessive flexing of muscles. Nerve impulses cause acetylcholine to be produced and travel across the gaps between nerves. When it binds to the second nerve, it fires, eventually stimulating the prospective muscle. Anticholinergics prevent the acetylcholine from binding to the second nerve, thus limiting muscle stimulation.
Anticholinergic side effects are typically mild, and can include dry mouth, blurred vision, and constipation. To avoid amplification of side effects, this drug is not usually prescribed along with antihistamines commonly used to treat allergies.
Common anticholinergic medications are:
- Benztropine mesylate
- Carbidopa-levodopa (Sinemet)
- Glycopyrrolate (Robinul)
- Procyclidine hydrochloride (Kemadrin)
- Trihexyphenidyl hydrochloride
Anticonvulsants (Seizure Medications)
Anticonvulsants are prescribed in hopes of reducing or preventing seizure activity. They also stabilize mood. Anticonvulsants reduce, or depress, excessive stimulation to the brain without affecting respiration or causing drowsiness. Different drugs control different types of seizures. To prescribe properly, the medical provider selects a type and dosage appropriate to the specific type of seizure the child is experiencing. The child is then monitored closely for any adverse reactions, which may result in a prescription or dosage change.
Prescriptions should be followed as prescribed so medications can be properly monitored and adjusted. Parents are urged to keep a journal of episodes and reactions for practitioner review.
Prescribed medicines may be changed or dosages altered based on the child’s reactions, or over time as the child’s body will likely build tolerance to the medication. A child’s dosage may be higher than what is required for an adult, as children process the drug faster. Individuals are known to respond to anticonvulsants differently.
Anticonvulsant dosage can be increased, but at a certain point it becomes advisable to switch medications – an event known as a changeover – altogether. If a changeover does occur, the child is weened from the previous medication to minimize or alleviate withdrawals. Withdrawals can cause anxiety, cramping, delirium, hallucinations, temper tandrums, trembling, and even death.
In some instances, practitioners will prescribe multiple drug therapy by combining more than one anticonvulsant. This increases the risk of adverse side-effects, drug interactions, and complicates the ability to analyze the reaction to the prescriptions.
Side-effects from anticonvulsants can vary depending on the drug prescribed, but may include constipation, convulsions, dizziness, drowsiness, fatigue, hair loss, headaches, incontinence, and nausea. Anticonvulsants may also cause a change in appetite, mood, weight, and vision.
Common anticonvulsants include:
- Gabapentin (Neurontin)
- Lamotrigine (Lamictal)
- Oxcarbazepine (Trileptal)
- Topiramate (Topamax)
- Zonisamide (Zonegran)
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Antidepressants (Depression Medications)
Antidepressants are psychiatric medications with mood altering and analgesic qualities used to treat depression, anxiety, and in some cases seizures. One-third of those with a chronic illness, such as cerebral palsy, may be depressed. Depression is a persistent sense of sadness, helplessness, and hopelessness.
The following factors inherent in impairment may contribute to an individual’s depression:
- Perceived limitations
- Chronic pain levels
- Perceived stigmas of those with disability
- Lack of control and coordination
- Dependence upon others
- Feelings of powerlessness
- Peer pressure
- Social isolation
In addition, depression can worsen the medical condition by:
- Aggravating the cerebral palsy
- Decreasing confidence
- Increasing fatigue
- Intensifying pain
- Worsening ability to cope
Not only are the individuals with chronic medical conditions at risk, but those who are caring for them are also susceptible to depression due to:
- the stress of caring for an individual with a chronic medical condition
- the challenges of day-to-day living with added responsibilities
- feelings of helplessness and hopelessness in not being able to cure the individual
- the emotional toll of a child’s diagnosis and the life-long realities of the condition
- the financial burden of disability
- sense of being overwhelmed
With depression comes loss of appetite, concentration, energy, interest, sleep, and pleasure. Other signs of depression may involve:
- Personality change
- Suicidal tendencies or thoughts
Surprisingly, research indicates a person is more prone to depression from lack of coping skills and perspective, rather than the actual severity of a medical condition. Some have reported the stigma associated with depression keeps individuals from seeking help. However, depression is highly treatable.
Treatment for depression is multi-faceted. Focus is on gaining emotional support, guidance, counseling, and perspective. Drug therapy can be used exclusively or in combination with any of the following:
- Behavioral therapy – to identify and address perception and gain new perspective
- Biofeedback and massage therapy – to relax, meditate, calm, peacefully escape, and energize
- Healthy diet and exercise – to provide the body the essentials to cope
- Sleep – to rest properly and re-energize
- Support groups – for emotional support and to relate to others in similar state
- Psychotherapy – for professional assistance to optimize mental health
The benefits of treatment for depression can be life-altering. Drug therapy changes the brain chemistry in a way that can be euphoric, provide hope, increase energy levels, supply optimism, enhance therapy participation, and provide the ability to cope with everyday life. A person who forgoes treatment for depression runs the risk of magnifying symptoms, and in some instances, developing suicidal tendencies. A person with depression may not always recognize or acknowledge their condition.
Antidepressants, in combination with other medicines, may result in serious side-effects and death. The primary medical provider should be aware of all the prescriptions, treatments and health conditions to thwart drug interactions, harmful side effects, or dangers. Antidepressants can also be harmful during pregnancy. If pregnancy is suspected, a doctor should be consulted immediately.
Side effects from antidepressants may include:
- Blurred vision
- Dry mouth
- Stomach upset
- Weight gain
Some commonly prescribed antidepressants include:
- Citalopram – Celexa
- Escitalopram – Lexapro
- Fluoxetine – Prozac
- Paroxetine – Paxil
- Sertraline – Zoloff
Antispastic (Muscle Relaxers)
Antispastics, also known as muscles relaxers, are prescribed to relax contracted, overactive, or stiff muscles. Antispastic medications are often the first treatment choice for reducing tremors or controlling widespread spasticity, as they are easy to use and non-invasive.
Antispastics can be administered orally in tablet form, or by injection directly into affected muscles or via the intrathecal baclofen pump, which is surgically implanted in the abdomen to deliver medication directly to the fluid that surrounds the spinal cord. Oral medications are usually prescribed for overall spasticity, while injections target a specific muscle. The benefits of oral medications and injections are usually short-term, requiring refills or further injections. The pump, on the other hand, provides steady doses of medication on a long-term basis. The pump must be maintained and refilled so as not to run the risk of abrupt withdrawals, or death.
The specific antispastic medication prescribed, as well as dosage, length of treatment, method of administration and the use of other complementary treatments vary with each individual and his or her circumstance. For example, oral medications, such as valium, are typically administered daily. Alcohol wash injections target specific nerves and can provide relief for a few months to several years. Botox is usually administered in three month intervals. Other injectable antispasmodics typically remain effective for about three to eight months. The intrathecal baclofen pump is found to be most effective on those with chronic, severe stiffness and those with uncontrolled muscle movements.
Some benefits derived from antispastic medications include:
- Control muscle contractions
- Delay surgery
- Increase range of motion
- Improve ability to participate in therapies
- Reduce impairment
- Reduce tremors and muscle spasms
- Relax overactive muscles
- Relax tight muscles
Possible side effects to antispastic medications, vary with the type, the individual, and the dosage, but may include:
- Flu-like symptoms
- General weakness
- High blood pressure
- Liver damage
- Pain upon injection
- Slowed heart rate
- Slurred speech
Medications vary in the way they relax muscles. Some, like baclofen, relax the muscle directly, while others, like diazepam, act on brain chemistry. Botox(R) causes mild muscle paralysis. Commonly prescribed antispastic medications include:
- Baclofen (Botulinum toxin, or Botox(R))
- Diazepam (Valium(R))
- Flexeril (Cyclobenzadrine)
- Dantrium (Dantrolene)
- Intrathecal Baclofen
Anti-Inflammatories (Pain Control)
Medscape reports 67%-84% of individuals with cerebral palsy experience bothersome pain lasting one hour or longer per episode. Anti-inflamatories address pain by reducing or alleviating inflammation.
Many medications and alternative treatments are available to manage pain often associated with cerebral palsy. Pain medications can range from over-the-counter (OTC) to prescription drugs, such as non-steroidal, anti-inflammatory drugs (NSAIDs) or anti-inflammatory corticosteroids. Many of these medications play a significant role in reducing pain as they alleviate the primary causes of discomfort. For minor pain, alternative therapies – hot or cold presses, acupuncture, or massage therapy, for example – may be considered.
Pain can result from the actual health conditions involved with cerebral palsy, or can be experienced when exercising, strengthening and expanding range-of-motion during physical therapy. Pain also results from surgery and post-operative healing, or even from medications injected or administered through a pump. Adjusting to and using orthotics can cause painful sores, while adaptive equipment can cause discomfort from pressure and continual use. Treatment of these, and other sources of pain, can increase overall health.
Some common origins of pain in those with cerebral palsy, include:
- Gastrointestinal pain – abdominal pain related to digestive complications from malnutrition, malabsorption, impaired orofacial functioning, esophageal issues, aspiration, incontinence, constipation and flatulence.
- Orthopedic pain – deformity, compensation, subluxation, degeneration, and dislocation found in the face, fingers, hands, arms, shoulders, back, spine, hips, pelvis, legs, ankles, feet or toes. Procedures performed on the bones, ligaments, joints, tendons, muscles, and nerves. Orthotic overuse, underuse, skin irritation, and rubbing can cause pain, as well.
- Pharmaceutical interventions – needle injections, including blood draws, pain medication, intravenous therapy, nasogastric tube placement, and anesthesia
- Rehabilitative therapies - pain worsened by therapy sessions involving assisted stretching and range of motion exercises, including occupational, physical, speech and language therapy.
- Surgical pain – pain derived from surgical procedure, post-operative healing, and needle injections such as blood draws, pain medication, and intravenous feeds.
Pain medication can be helpful in reducing or alleviating pain. Not all pain medication can be taken by children or women who may be pregnant. All medications should be cleared by the primary care physician who will ensure there are no adverse effects, can monitor the effectiveness, can check for drug interactions, and is knowledgeable in properly prescribing the drug and its assigned dosage. Four main categories of anti-inflammatories include:
- Aspirin – suppresses prostaglandins, regulates body temperature, and constricts blood.
- Corticosteroids – anti-inflammatory agent with a large number of other functions, such as glucose utilization, fat metabolism, and bone development.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – a non-steroid substance which has analgesic, antipyretic, and platelet producing capabilities to primarily treat mild to moderate pain, and fever.
- Steroids – decrease inflammation and reduce immune system activity.
Constipation, a dry, hard stool that is difficult and possibly painful to pass, is common in children with cerebral palsy. The condition can be caused by medications, lack of activity, inadequate fluid intake, dietary complications, difficulty in accessing bathrooms and labored breathing.
The primary way to treat constipation is with a healthy diet rich in high-fiber foods. Laxatives, which can be very useful, come in several forms. Stool softeners help to maintain water content to prevent stool from becoming hard and painful. Various stimulants induce bowel contractions and move stool along the intestinal tract.