Established care
Spasticity and tone management
Botulinum toxin, orthoses, serial casting, oral medication, baclofen pump, selective dorsal rhizotomy
Medical and surgical treatment of tone, which works best when it is tied to a functional goal rather than to a number on a tone scale.
Either a medicines regulator has licensed it for this use, or clinical practice guidelines recommend it on the strength of controlled trials. This is the standard everything else on the scale is measured against — and for most children, the treatments at this level are the ones that will actually change their day.
Where it stands, condition by condition
The same therapy can be well supported for one problem and completely untested for another. This is the single most common place families are misled.
| Condition | Evidence | What that means here |
|---|---|---|
| Focal spasticity — botulinum toxin | Established care | Licensed and guideline-supported for focal spasticity in children, as part of an integrated programme with therapy. |
| Generalised spasticity — intrathecal baclofen | Established care | Established for selected children with severe generalised spasticity, in specialist centres. |
| Selective dorsal rhizotomy | Established care | Established for carefully selected children, most often ambulant children with spastic diplegia. Selection is the whole question. |
| Oral antispasticity medication | In clinical trials | Widely used; evidence for functional benefit in children is modest and side effects limit dose. |
| Serial casting and orthoses | Established care | Supported for specific goals such as improving ankle range or foot position in walking. |
What it is
Spasticity is velocity-dependent resistance to movement. It is one component of the motor problem, alongside weakness, poor selective control and, in some children, dystonia — which is a different problem and responds differently.
Options range from orthoses and casting, through injected botulinum toxin, to oral medication, an implanted baclofen pump, and neurosurgery.
Every one of them is an adjunct. None replaces therapy; they create a window in which therapy can achieve more.
How it is meant to work
Reducing tone can make a joint easier to move, a brace easier to tolerate and a muscle easier to lengthen or strengthen. It does not add strength or control.
This is why the common disappointment happens: tone falls, the number on the scale improves, and nothing the child does changes — because nobody attached a functional goal and a therapy block to it.
What has actually been tested
- Botulinum toxin reliably reduces focal tone, and improves function when it is paired with therapy directed at a specific goal.
- Selective dorsal rhizotomy produces durable tone reduction in appropriately selected children; outcomes depend heavily on selection, surgical centre and the rehabilitation that follows.
- Intrathecal baclofen helps severe generalised spasticity, including for comfort and care in non-ambulant children, at the cost of a device that needs maintenance.
- Distinguishing spasticity from dystonia matters, because several of these treatments work less well, or differently, in dystonia.
What we still do not know
- Optimal timing and frequency of botulinum injections, and the long-term effect of repeated cycles on muscle.
- Which children benefit most from rhizotomy versus continued conservative management.
- How much tone reduction is useful before it unmasks weakness.
Risks and costs
- Botulinum toxin: local weakness, pain, and rarely spread of effect; repeated injections need anaesthesia or sedation in young children.
- Baclofen pump: infection, catheter failure, and withdrawal if the pump fails — a medical emergency families must be taught to recognise.
- Rhizotomy: irreversible, with weakness and sensory change as recognised trade-offs.
- The commonest harm is subtler — treating tone as the target and forgetting the goal.
Questions to ask before you agree
A centre that is doing good work will welcome these questions and answer them in writing.
- What functional goal is this aimed at, and how will we measure it?
- What therapy follows, and is it booked?
- Is this spasticity or dystonia, and does that change the choice?
- If this works, what is the plan for the next three years — and if it does not, what then?
More in this section
Early detection and early intervention
The single highest-value thing in this whole field, and the one least often discussed in clinics selling treatment. Cerebral palsy can be identified in the first months of life, and that is when therapy does the most.
Established careGoal-directed, task-specific training
Not a brand of therapy but the principle underneath the ones that work: the child practises the actual task they are trying to learn, with enough repetition to matter.
Established careConstraint-induced therapy and bimanual training
For a child who uses one hand much more than the other, these are among the best-evidenced interventions in paediatric neurology — and both work, for different things.
Established carePhysiotherapy and strength training
Well supported when it is built around function and genuinely loaded — much weaker when it is passive stretching and generic exercise.
Established careOccupational therapy
The discipline that works on what the child actually does all day — dressing, eating, writing, playing, getting through a school morning.
Established careSpeech, language and communication
For a child who cannot speak clearly, giving them a way to communicate is among the most consequential interventions available — and the fear that it will stop them talking is unfounded.
In clinical trialsTechnology-assisted rehabilitation
Useful mainly as a way of delivering more practice, not as a treatment in its own right — and that distinction decides whether it is worth the money.
In clinical trialsNamed physiotherapy approaches
Families are usually asked to choose between brands. The evidence says the brand matters far less than whether the session is active, goal-directed and repeated often enough.
In clinical trialsSensory therapies
Two things are sold under one word. Manualised Ayres Sensory Integration has been tested in trials; the sensory add-ons sold around it mostly have not.
Established careVision and cerebral visual impairment
The most commonly missed problem in children with brain injury. A child who cannot interpret what they see is often described as inattentive, uncooperative or more delayed than they are.