Interventions+for+Spasticity+in+Children

Interventions for Spasticity in Children Kylie Cooper, Emily Janssen, Ellie Mohr, and Emily Orscheln

PubMed, Google Scholar, Cochrane...
 * “Spasticity AND children”
 * “Selective dorsal rhizotomy”
 * “Interventions AND Spasticity”
 * “Intrathecal Baclofen AND Spasticity”
 * “Botulinum Toxin AND Spasticity”
 * “Cerebral Palsy AND Interventions”
 * “Cerebral Palsy AND aquatics”

== = = = What is spasticity? =
 * = Form of hypertonia, or increase muscle tone resulting from upper motor neuron lesion. This results in stiff muscles which can make movement difficult or even impossible. 1 =
 * = Muscles appear stiff because messages to the muscles are sent incorrectly through the damaged part of the the brain. It is characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks. 1 =
 * = Spasticity is found in many different condition such as stroke, traumatic brain injuries, spinal cord injury and multiple sclerosis, however cerebral palsy being specific to the pediatric population 1 =




 * What does spasticity look like? **

Effect on the upper limbs (arms and hands) If spasticity affects one or both of the arms it can lead to: Spasticity in these areas can lead to difficulties with tasks involving the hands and the arms It may also affect a person’s ability to use their arms for balance which can lead to difficulty standing and walking.
 * Flexion at the elbow
 * Flexion at the wrist
 * Flexion at the fingers

If spasticity affects one or both of the legs it can lead to:
 * Effect on the lower limbs (legs) **
 * Flexion at the hip
 * Adduction or ‘scissoring’ of the thighs
 * Flexion at the knees
 * Equinovarus foot posture


 * How is Spasticity Assessed? **
 * Look at which muscles are affected by spasticity
 * Severity of the spasticity in each muscle affected
 * How a patient is able to control their muscles
 * Any secondary effects of spasticity which affects the person's ability to perform functional tasks.
 * A functional assessment which will include observation of the person performing daily activities in natural environment.
 * MAS scores: measures resistance during passive soft tissue stretching done at the speed of gravity (aka fast)

There is no specific diagnostic test to confirm spasticity. Tests are instead performed to rule out other causes: Brain/spinal cord lesions, seizures, and neurodegenerative diseases. Stretching will help differentiate: rigidity will decrease with stretching whereas spasticity will continually increase as the velocity of stretching increases.
 * Diagnosis **

__** What is Cerebral Palsy? **__
 * Congenital disorder of movement, muscle tone, or posture. Cerebral Palsy is due to abnormal brain development, often before birth.
 * Can’t be cured, but treatment may help

Intervention I: Physical Therapy


 * Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews ** 2

The purpose of the study was to review the evidence on positive and negative effects of PRE as a physical therapy intervention. Principles of progressive resistance exercise (PRE) for increasing force production in muscles
 * Perform a small number of repetitions until fatigue
 * To allow sufficient rest between exercises for recovery
 * To increase the resistance as the ability to generate force increases

The studies included children and adults aged from 4 to 47 years with spastic hemiplegia, diplegia, or quadriplegia alone or in combination, as well as a small number of people with ataxia or dystonia. 2
 * PRE for Children with Cerebral Palsy **
 * PRE program: 2-4 exercises using isokinetic dynamometers, weight machines, or free weights
 * Participants typically completed 3 or 4 sets of 5 to 10 repetitions of each exercise with a training intensity of 50-65% of 1RM.
 * Participants usually trained 3 times per week for periods ranging from 6 to 10 weeks.

Both RCT concluded that there is strong evidence supporting PRE resulting in increased ability to generate muscle force in people with CP. 2


 * Effects of PRE in patients with Cerebral Palsy **
 * There is an overall clinical concern that the exercise intensity required during PRE will increase hypertonia in children with spastic CP. This in turn leading to decreased ROM and stiffness.
 * This was investigated in one review and concluded that participation in a PRE program did not have negative effect on hypertonia.
 * The study found that there was however a significant increase in ROM after completion of the PRE program.

The current study demonstrated that CPM to the knee joint at an angular velocity of 15°/s for 20 minutes decreased muscular hypertonia and improved ambulatory function in children with cerebral palsy. Whether the effects would last for a longer period of time and demonstrate clinical significance need further investigation 4
 * Managing spastic hypertonia in children with cerebral palsy via repetitive passive knee movements ** 4
 * Passive ROM was applied to the subject's (16 subjects) knees with a continuous passive motion device at 15-0 degrees per second for 20 min. Effects were evaluated measuring range-of-motion, muscle tone, and ambulatory function before, immediately after, and 30 min after intervention.
 * Increase in
 * AROM of the knee
 * Relaxation index
 * 6 - Minute walk test
 * Decrease in:
 * Modified Ashworth Scale
 * Timed up and Go

Aquatic therapy is one of the most popular supplementary treatments for children with neuromotor impairments. The level of spasticity was considerably decreased after therapy according to the use of the Modified Ashworthy Scale (MAS)Proving that aquatic exercise can be useful in reducing spasticity in children with spastic CP. 3 = =
 * Managing Spasticity with Aquatic Therapy ** 3
 * This study examined aquatic exercise effects on gross motor functions, muscle tone and cardiorespiratory endurance in children with spastic CP.
 * Looked at 19 children ages 6-12 with spastic CP.
 * 12 week aquatic program. 2 times per week.
 * The aquatic therapy consisted of
 * 10 minutes of light warm-up in the water (forward and backward walking, jumping, and other such exercises)
 * 40 minutes of exercise swimming techniques (prone and back gliding from the wall; prone and back floating; blowing bubbles; breaststroke, backstroke or freestyle techniques; diving to the pool bottom)
 * 5 minutes of play (ball games, chasing games, etc.)

** Intervention II: Botulinum Toxin Type a **


 * Botulinum Toxain A or BoNT-A are prescription drugs made from the bacteria clostridium botulinum. It is the same drug used for the cosmetic effects that come to mind when we think BOTOX. 9
 * BoNT-A works by paralyzing or weakening the muscles it is injected into by blocking the signal between nerves and muscles by inhibiting the release of ACH at the presynaptic neuron. []
 * It was stated that treating spasticity can use up to 100x the amount needed to treat frown lines. 9

Applying a local anesthetic cream 2 hours prior to injection
 * According to Cincinnati’s children's hospital the injection process consists of: ** 8
 * The treatment is given via a 27 gauge needle in the examination in the previously determined muscles
 * o Should be delivered at the motor endplate of the muscle and guiding of the needle can be done by EMG, ultrasound and palpation
 * o The injection needs to be spread throughout the muscle so multiple injection in the muscle are NOT uncommon
 * After the injection there is an short observation time and the the patient can return home and to their normal activities as the injection is active after 24 hours
 * Changes in motor function can be seen in 1 to 2 weeks (peak time)
 * Repeat injections can be done after 3 months
 * Side effects are normally mild
 * muscle weakness, near injection site, bleeding, bruising, flu like symptoms and muscle stiffness


 * Why Used in Children with CP? **


 * The use of Botox in children with CP is used to improve function and support motor development by helping relax the spastic muscles. 6
 * Like the other Interventions for Spasticity in children with CP, this intervention is apart of a multimodal treatment based on an individualized IFC model. 6


 * Effects of leg muscle botulinum toxin A injections on walking in children with spasticity-related cerebral palsy: a systematic review ** 7

Study Goal: Outcome measures: Quality Assessed: Ages included: Subgroups: Conclusion
 * To see the effects of Botulinum Toxin Type A with physical therapy on walking of children with leg spasticity due to spasticity compared to physical therapy alone
 * CINHAL, Cochrane, PEDro, EMBASE and PubMed were all systematically searched looking for RCT’s on assessing functional outcomes on walking of children with CP,
 * o 8 studies met inclusion criteria and were apart of the systematic review
 * GMFCS (Gross Motor Functional Scale)
 * o Scores based on sitting, walking and using mobility devices. Focus on MOTOR FUNCTION
 * o Levels I-V (one being the most independent
 * PRS (Physician rating scale)
 * o A measure for gait analysis and ROM
 * PEDro scale used to assess the quality of RCT’s included in the study
 * 1 year and 7 months to 10 years with Spastic CP at various levels of spasticity
 * 1. BoNT-A injections with Physical therapy vs Physical therapy alone
 * 2. BoNT-A injections and casting vs. casting alone
 * This study revealed significant improvements with the BoNT-A and Physical Therapy compared to the patients who received Physical therapy alone
 * In regards to the second group, there was no significant evidence between the injections and casting vs casting alone
 * This systematic review revealed the benefits of BoNT-A combined with physical therapy for short and long term effects 7


 * A randomized trial of upper limb botulinum toxin versus placebo injection, combined with physiotherapy, in children with hemiplegia ** 5


 * Study Design
 * o Prospective double blind parallel arm simple randomized control trial comparing effects of BoNT- A injection combined with intensive individualized PT program, compared to a placebo injection combined with the intensive PT treatment. This study worked on ruling out the placebo effect
 * Participants
 * o Children with hemiplegic cerebral palsy (HCP) were included
 * o 27 children including 13 females and 14 males and a mean age of 6.27 years
 * o Participants were randomly assigned into two groups
 * BoNT-A injection
 * Placebo injection (saline solution)
 * Both received injections into the elbow area, forearm, and hand
 * Both also received a standardized individualized PT treatment 3 times a week for 45 minutes ongoing for 24 weeks focusing on functional activities
 * Outcome measures
 * These outcome measures were taken at baseline 1, 3 and 6 months after the injection
 * o Body functions and structures:
 * grip strength with dynamometric measure, Modified Ashworth Sclae (MAS) and Physician Rating Scale of UL (PRS; active ROM)
 * o Activity and daily life:
 * Assisting Hand Assessment (AHA) was used to measure the use of the affected UL in activities, Pediatric Evaluation of Disability Inventory (PEDI) a questionnaire around daily life and self care
 * Clinical Analysis
 * o Statistical Package for Social Services using
 * o 2 sample t-tests
 * o Mann-Whitney test to assess between group [[image:https://lh5.googleusercontent.com/-R6pvKz_jG9Uf3fl8Wg6k0Pq2PnrbjuBZKizhbQCl-QX0kFgRTrn0VSlvpF9WYhfp5uPaIfTzaZCed_fiZwy7kjaqTn0WDG-kGS0pfBHn82dA2nnwDDMUU7QNjsNadKdJfsLUZKYupQ width="417" height="235" align="right"]]
 * Results
 * Activity-
 * o AHA scores were higher in the BoNT-A compared to placebo
 * p= .025
 * Daily Life –
 * PEDI FS (functional skill) and CA (caregiver assistance) showed positive scores in intervention group but was not statistically significant
 * Body functions and structures –
 * MAS nor PRS showed statistical significance
 * GAS (goal attainment scaling) –
 * results were in favor of BoNT-A group, there was a large change at T2 or 3 months post injection, but some improvement was not seen at T3, or 6 months after injection
 * p=.03


 * Conclusion
 * There was a noticeable increase in AHA up to 3 months but at 6 months the involvements seemed to stop, while the placebo group continued to improve this could be attributed to the injection losing its effect on the muscles.
 * The placebo group of PT intensive therapy was slower but more consistent up to the 6 month time interval
 * Age did not seem to have a difference on their scores
 * So in conclusion, BoNT-A was effective in the short term but PT interventions may show progress slower but seem to be more consistent and are still effective after 6 months 5


 * OVERALL: **
 * It seems the evidence points to the benefits of BoNT-A with Physical therapy are positive for the upper and lower limb muscles, the downfall is these injections do not last forever, the effects of these injections last only 3-4 months. Physical Therapy in both studies proved to show improvements, even though slower than the BoNT-A groups, over the 6 months time period is was shown to be more consistent and improvements continued.
 * BoNT-A also affects every child differently, it may be more effective for some children but show no or minimal effects in other children. If used then best results occur with a goal directed functional physical therapy program.

** Intervention III: Selective Dorsal Rhizotomy **

Selective Dorsal Rhizotomy is a surgical procedure in which the dorsal (sensory) nerve roots L2-S2 are exposed and independently stimulated. This is monitored visually and through EMG. Those that elicit excessive activity are cut (normally about 25-50%). It is a very meticulous procedure requiring anesthesia and a neurophysiologist who must be present to determine which nerve is to be severed. This procedure is usually performed in children with spastic cerebral palsy. In children with cerebral palsy, the brain is not sending the appropriate signals to inhibit some of the muscles signals of increased tone. As a result, children have too much input from the muscles causing spasticity. The goal of a selective dorsal rhizotomy is to cut the sensory nerves and “to better balance the messages of flexibility from the brain with messages of stiffness from the muscle.” 1



One study sought to determine if there were any “preoperative clinical characteristics that might be predictive of a poor outcome after selective dorsal rhizotomy (SDR).” 10 In a retrospective analysis of 174 children who had undergone selective dorsal rhizotomy between 1983 and 2001, patients were divided into two groups: “acceptable” or “poor” outcomes. Many factors were considered as possible predictors: age at the time of the operation, the type of cerebral palsy, history of seizures, history of lower limb orthopedic surgeries, history of prematurity, different postural abnormalities, ambulatory function, and preoperative GMFCS scores. Though the study’s goal was to determine possible predictors to poor surgical outcomes, it actually served to support the effectiveness of SDR for most types of patients with CP. Of the 174 patients in the study, only 11 had poor responses to the procedure. This made it difficult to form a model that would allow one to select possible poor responders to SDR with any accuracy. Even though the results did indicate that patients with quadriplegia were more likely to do poorly, 86% of the children with quadriplegia benefitted from the SDR. The diagnosis of quadriplegia type of CP should not exclude a child from consideration for SDR. 10

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“Conventionally, selective dorsal rhizotomy (SDR) has been reserved for ambulant children and implantation of intrathecal baclofen (ITB) pump for non-ambulant children with cerebral palsy.” 11 In patients with GMFCS grades of 4 and 5 with ITB pumps that needed replacing (due to infection or depletion of drug delivery system), this study elected to instead perform SDR. With a small sample size of 10 children with severe spasticity, it was found that mean Ashworth scores decreased in both the upper and lower limbs (1.70 and 2.4 respectively), 27% of patients experienced improvement with urological function, and overall 90% of parents/caretakers “felt that functional outcomes with SDR were improved compared with that of ITB.” 11 The benefits were preserved up to the 8 month follow-up, and in half of the patients the benefits were still sustained at the 14 month follow-up. Most saw a reduction of anti-spasticity medications. The ease of motion improved after surgery, but the range of motion remained the same. 2 of the 3 GMFCS IV children showed some gait improvements and a child who was previously immobile was able to crawl. 11

A randomized controlled single-blind trial completed by Steinbock et al sought to compare the results of selective posterior rhizotomy (SPR) and intensive therapy to that of intensive therapy alone. The goal was to determine which approach would better improve the motor function of children with spastic diplegic cerebral palsy. The SPR group underwent a rhizotomy and then followed up with intensive therapy for 9 months. The group assigned to therapy only had identical intensive therapy as the SPR group. At 9 months the SPR group had a 11.3% increase in total Gross Motor Function Measure (OMFM) compared to 5.2% in the therapy only group. This was a “statistically significant and clinically important difference in improvement in motor function in favor of the SRP group.” 12 There were also significant improvements in spasticity and range of motion.

A systematic review and a meta-analysis have summarized the positive effects of SDR in the short-term. Both studies illustrated that SDR has a positive influence on the ICF body structure and functions and activity domains. 13 The meta-analysis Grunt et al referenced compared 3 studies and looked at their 9- and 12-month outcomes after SDR: a clinically important change in spasticity was confirmed. These three studies also showed a low rate of serious adverse events due to the SDR intervention. 14

** Conclusion on Selective Dorsal Rhizotomy ** Selective Dorsal Rhizotomy (SDR) has been used for the last few decades as a way to treat spasticity caused by cerebral palsy (CP). Studies suggest that SDR is less invasive than other treatments, 11 and can be a viable option for many children with various types of spastic CP, 10 and in younger patients, it can reduce the need for future orthopedic surgery. 15 The best improvements in motor function and spasticity are seen in patients that participate in therapy following SDR as opposed to therapy alone. 12 Each of these studies lacks evidence that any serious adverse events are attributable to SDR procedure. Short term (less than 5 years) improvement was shown in patients with spasticity undergoing SDR. 13,14 Though there are many studies available addressing SDR as a treatment to spasticity in children, there is a lack of sufficient evidence to conclude and generalize any long-term positive effects of SDR with children with spasticity. 13 There is a need for long term studies that follow patients for 20+ years to determine the outcomes of surgery and the effects on mobility and daily function. There was, however, very strong evidence for the benefits of SDR in impairment, the decrease in lower limb spasticity, and the increase in lower limb range of motion. There is also strong evidence that SDR has a positive impact on functional imitation with improvements in motor function (GMFCS). 16 Each source supported intensive therapy as a follow up after the SDR intervention. The outcomes from the SDR would not be seen or beneficial to a patient without participation in therapeutic intervention. Similarly, the results of therapy after a SDR is not “simply the result of intensive physiotherapy.” 12 Though the outcomes are very encouraging there is still only a fair amount of research at this time. Much more needs to be done to come to a strong conclusion about Selective Dorsal Rhizotomy as a treatment for spasticity.

** Intervention IV: Intrathecal baclofen treatment (ITB) ** ITB is a surgically implanted system used to control spasticity by infusing baclofen directly into the spinal canal and around the spinal cord. Baclofen is a GABA receptor agonist that blocks excitatory neurotransmitters to relax skeletal muscle and depress CNS activity. Implantation is contraindicated if the patient is of insufficient body size, requires a pump implant deeper than 2.5 cm, or, in the presence of spinal anomalies or active infection, or is hypersensitive to baclofen. Most frequent drug adverse events include: hypotonia (34.7%), drowsiness (20.9%), headache (10.7%), convulsion (10.0%), dizziness (8.0%), urinary retention (8.0%), nausea (7.3%), and paresthesia (6.7%). 17
 * Evidence: **


 * Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin **
 * Methods: A prospective, multicenter study was conducted in 68 patients who had been enrolled in the initial evaluation of ITB therapy and were willing to participate in long-term surveillance.The patients were examined at least every 3 months and were observed for an average of 70 months using the Ashworth Scale
 * Results: Spasticity in both upper and lower extremities decreased significantly (p < 0.005) and remained decreased up to 10 years. Adverse events resulted in 50% of patients.
 * Conclusions: Intrathecal baclofen provides effective long-term treatment of spasticity of cerebral origin and its effects do not appear to diminish with time. This therapy is frequently associated with adverse side effects that usually can be alleviated by adjustments in dosage.
 * Caution: Is the Ashworth Scale alone reliable in measuring spasticity and changes in spasticity over time? 18


 * Use of intrathecal baclofen therapy in ambulant children and adolescents with spasticity and dystonia of cerebral origin: a systematic review. **
 * Method: MEDLINE, CINAHL, PsycINFO, EMBASE, full Cochrane Library, and PEDro were searched
 * Inclusion criteria: subjects received ITB therapy, had spasticity of cerebral origin, were able to ambulate, Gross Motor Level function of 1-3, and were 18 or under
 * Results: Two independent reviewers scored 16 studies against the guidelines for developing systematic reviews from the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM).15 studies level 4 or 5 evidence and 1 level 2 study (all low quality).
 * Conclusions: ITB seemed unable to improve the ambulatory status of the participants from non-ambulatory to ambulatory or to reduce the level of assistance required during their ambulat ion. Improvement was shown in participants’ ability to perform specific gross motor activities after ITB and ability to walk in those who were previously ambulatory. In conclusion, there was no evidence to support the clinical use of ITB in ambulant individuals with hypertonicity without further rigorous longitudinal studies. 19


 * Intrathecal baclofen for treating spasticity in children with cerebral palsy (Systematic Review) **
 * Methods: searched the CENTRAL, MEDLINE, EMBASE and CINAHL databases, handsearched recent conference proceedings, and communicated with researchers in the field and pharmaceutical and drug delivery system companies. Randomized controlled trials were sought after because they are thought to be the highest level of evidence.
 * Data Collection and Analysis: two authors selected studies, two authors extracted data and two authors assessed the methodological quality of included studies
 * Results: 6 studies met inclusion criteria. 5 out of 6 were RCT but were found to be unclear or highly biased. 4 studies used short-term administration, 1 study assessed long-term.
 * Author’s Conclusions: there is some limited short-term evidence that intrathecal baclofen is an effective therapy for reducing spasticity in children with cerebral palsy. This evidence is limited by small sample sizes and methodological issues. Further investigation is needed. 20

Currently, quality of evidence for most for studies involving ITB therapy for spasticity in children is low, even though many studies state significant differences post ITB therapy. There is a need to identify good candidates for ITB based on the ICF model. Cohort longitudinal studies could help provide more higher level evidence that could result in clinically significant differences. There is a need for the use of objective standardized outcome measures, especially at the activity and participation levels 19. Many adverse effects were reported with ITB treatment, which is a concern for those considering treatment for their children. 18 High levels of evidence may be limited due to the difficulty of performing RCT for this special population with such a wide spectrum of presentations. Based on current evidence, we would recommend ITB for reduction in short-term spasticity for certain children with CP. 20
 * Overall conclusions with baclofen and spasticity **

** What does this mean for us as future physical therapists?: **
Each of these interventions can be vital to the treatment of spasticity in children and multiple options are often used. These treatment options are not part of the PT scope of practice and only little information is available in the PT Guide. But it is crucial that every patient participate in therapy after their personalized treatments are performed. Without therapy as a follow up, the reductions in spasticity will not lead to increased range of motion, flexibility, motor function, or ambulation.


 * Resources **
 * 1) St. Louis Children’s Hospital. Selective Dorsal Rhizotomy. Dep Neurosurg St Louis Child Hosp. 2007.
 * 2) Taylor NF, Dodd KJ, Damiano DL. Progressive resistance exercises in physical therapy: A summary of systematic reviews. Physical Therapy Journal. 2005; 85(11): 1208-1223.
 * 3) Dimitrijević L, Aleksandrović M, Madić D, Okičić T, Radovanović D, Daly D. The Effect of Aquatic Intervention on the Gross Motor Function and Aquatic Skills in Children with Cerebral Palsy. Journal of Human Kinetics 2012;32(-1). doi:10.2478/v10078-012-0033-5.
 * 4) Cheng H, Ju Y, Chen C, Wong M. Managing spastic hypertonia in children with cerebral palsy via repetitive passive knee movements. J Rehabil Med Journal of Rehabilitation Medicine 2012;44(3):235–240. doi:10.2340/16501977-0937.
 * 5) Ferrari A, Maoret AR, Muzzini S, et al. A randomized trial of upper limb botulimun toxin versus placebo injection, combined with physiotherapy, in children with hemiplegia. Research in Developmental Disabilities 2014;35(10):2505–2513. doi:10.1016/j.ridd.2014.06.001.
 * 6) Strobl W, Theologis T, Brunner R, et al. Best Clinical Practice in Botulinum Toxin Treatment for Children with Cerebral Palsy. Toxins 2015;7(5):1629–1648. doi:10.3390/toxins7051629.
 * 7) Ryll U, Bastiaenen C, Bie RD, Staal B. Effects of leg muscle botulinum toxin A injections on walking in children with spasticity-related cerebral palsy: a systematic review. Developmental Medicine & Child Neurology 2011;53(3):210–216. doi:10.1111/j.1469-8749.2010.03890.x.
 * 8) http://www.cincinnatichildrens.org/health/b/botox/
 * 9) []
 * 10) Kim HS, Steinbok P, Wickenheiser D. Predictors of poor outcome after selective dorsal rhizotomy in treatment of spastic cerebral palsy. Child’s Nerv Syst. 2006;22(1):60-66. doi:10.1007/s00381-005-1160-2.
 * 11) Ingale H, Ughratdar I, Muquit S, Moussa AA, Vloeberghs MH. Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children. Childs Nerv Syst. 2016;32(2):321-325. doi:10.1007/s00381-015-2950-9.
 * 12) Steinbok P, Reiner AM, Beauchamp R, Armstrong RW, Cochrane DD. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 2008;39(3):178-184. doi:10.1111/j.1469-8749.1997.tb07407.x.
 * 13) Grunt S, Becher JG, Vermeulen RJ. Long-term outcome and adverse effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2011;53(6):490-498. doi:10.1111/j.1469-8749.2011.03912.x.
 * 14) McLaughlin J, Bjornson K, Temkin N, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002;44:17-25. doi:10.1097/00004703-200206000-00024.
 * 15) Chicoine MR, Park TS, Kaufman B a. Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy. J Neurosurg. 1997;86(1):34-39. doi:10.3171/jns.1997.86.1.0034.
 * 16) Steinbok P. Outcomes after selective dorsal rhizotomy for spastic cerebral palsy. Child’s Nerv Syst. 2001;17:1-18.
 * 17) SCI Forum Report & Video. Intrathecal Baclofen Therapy for Spasticity. Available at: http://sci.washington.edu/info/forums/reports/intrathecal_baclofen.asp. Accessed April 19, 2016.
 * 18) Albright AL, Gilmartin R, Swift D, Krach LE, Ivanhoe CB, Mclaughlin JF. Long-term intrathecal baclofen therapy for severe spasticity of cerebral origin. Journal of Neurosurgery 2003;98(2):291–295. doi:10.3171/jns.2003.98.2.0291.
 * 19) Pin TW, Mccartney L, Lewis J, Waugh M-C. Use of intrathecal baclofen therapy in ambulant children and adolescents with spasticity and dystonia of cerebral origin: a systematic review. Developmental Medicine & Child Neurology 2011;53(10):885–895. doi:10.1111/j.1469-8749.2011.03992.x.
 * 20) Hasnat MJ, Rice JE. Intrathecal baclofen for treating spasticity in children with cerebral palsy. Cochrane Database of Systematic Reviews Reviews 2015. doi:10.1002/14651858.cd004552.pub2.