Can Cerebral Palsy Be Cured?

Cerebral palsy (CP) is a group of permanent disorders of movement and posture that result from brain damage in early life. Over the past 20 years, many new approaches to CP rehabilitation have appeared, from device-based non-drug methods to pharmacological and biological therapies. Clinical studies of different treatments make it possible to assess their effectiveness and level of evidence. This report reviews the most important studies and advances (including those recognized by Nobel Prizes, where applicable) in CP treatment over the past two decades. It gives an assessment of each method, including the level of evidence (availability of randomized controlled trials, meta-analyses, etc.), reviews international experience and successful cases, and presents a detailed clinical treatment protocol with stages for introducing effective methods into practice.

Non-Drug Treatment Methods for Cerebral Palsy

Hyperbaric Oxygen Therapy (HBOT)

Hyperbaric oxygen therapy is a method in which the patient breathes 100% oxygen at increased pressure in a pressure chamber. In the 2000s, HBOT attracted attention as a potential therapy for CP. However, the accumulated evidence suggests that HBOT does not provide a specific improvement in CP. A meta-analysis of 5 high-quality RCTs showed that children who received HBOT sessions (1.5–1.75 ATA, 100% O₂) had the same improvements in motor and cognitive function as control groups (who received either pressurized air or standard rehabilitation). In other words, the effect of HBOT does not exceed the effect of placebo therapy under pressure or of regular physical therapy. Moreover, side effects are fairly common with HBOT: up to 50% of children had middle-ear barotrauma (damage to the eardrum) and other minor complications. Conclusion: HBOT has not demonstrated effectiveness in improving the condition of children with CP (evidence level Ia, meta-analysis of RCTs) and may be accompanied by undesirable effects, so its use is not recommended as a standard treatment.

Neurobiofeedback Therapy (Biological Feedback)

Biofeedback therapy uses devices that give the patient feedback about their physiological processes (for example, muscle activity or brain activity) in order to teach better control of movements or muscle relaxation. Various types of biofeedback have been used in CP rehabilitation: EMG biofeedback for muscle training (for example, during walking), EEG neurofeedback to improve cognitive function and attention, and others.

A systematic review of 57 studies (both controlled and uncontrolled) found that ~79% of studies reported improved motor function after biofeedback interventions. In particular, improvements in balance, coordination of movements, and fine motor skills were reported after a course of biofeedback training. However, it should be emphasized that the quality of the evidence is very low: most studies had an uncontrolled design and differed in methods and assessment criteria. According to the conclusion of this review, although biofeedback may improve motor outcomes in children with CP, the certainty of the evidence was rated "very low". Further standardized RCTs are needed to determine its effectiveness precisely.

Separately, EEG neurofeedback is being studied for children with CP who have attention or learning problems. A pilot RCT (19 children with CP and attention disorders) showed that 20 neurofeedback sessions targeting specific EEG parameters led to a decrease in pathological theta/beta brain rhythm and improved attention and visual memory compared with the control group. The authors concluded that neurofeedback may have a positive effect on attention in children with CP, although these are preliminary data.

Thus, biofeedback and neurofeedback therapy are promising non-drug methods that have shown individual successful cases of improved motor and cognitive function. However, because of the lack of large, high-quality studies, they should be regarded as supplementary methods with a still insufficient evidence base.

Transcranial Direct Current Stimulation (tDCS)

Transcranial direct current stimulation is a method of low-intensity electrical brain stimulation through electrodes on the scalp. In recent years, tDCS has been tested as a way to enhance neuroplasticity in CP.

Available studies suggest that tDCS is safe for children (side effects are minimal) and potentially effective when combined with physical rehabilitation. In particular, a double-blind RCT involving 24 children aged 5–12 compared 2 weeks of treadmill gait training with active tDCS over the motor cortex against training with sham tDCS. The active tDCS group showed greater improvement in balance and functional gait: body sway area decreased, and balance scale scores improved one week and one month after therapy. The study concluded that treadmill walking with anodal tDCS led to significant improvements in static balance and functional performance.

A review and meta-analysis of tDCS for motor disorders in children (including CP) partly supports these findings: tDCS is well tolerated and safe, and it may improve certain gait parameters and reduce involuntary movements. At the same time, the effect of tDCS on balance and hand function is less pronounced or inconsistent across studies. In other words, tDCS is regarded as a promising adjunct to rehabilitation, but its effectiveness depends on the specific goals (it works better for improving gait than, for example, fine motor skills) and the evidence is still limited. In practice, tDCS can be introduced in specialized centers as a supplement to physical therapy and robotic therapy, with careful monitoring of results.

Transcranial Magnetic Stimulation (TMS)

Transcranial magnetic stimulation uses brief magnetic pulses to stimulate areas of the brain non-invasively. Repetitive TMS (rTMS) has been studied as a way to improve motor function and speech in CP.

A meta-analysis of 29 studies (including many RCTs from different countries, among them China) that assessed the effectiveness of rTMS in children with CP was published recently. Results: the rTMS groups showed a significant improvement in motor function, with higher Gross Motor Function Measure (GMFM) and Fine Motor Function Measure scores compared with controls. Improved language skills were also reported, in the form of higher speech development scores after rTMS. Although individual studies had small samples, the combined effect was statistically significant. The review concluded that rTMS may improve motor function and speech in patients with CP.

Importantly, rTMS protocols differed substantially between studies (different stimulation frequency, number of sessions, and combination with physical therapy). Most of the included studies were relatively small, and by GRADE criteria the quality of evidence varied: mostly low or moderate. However, none of the studies identified serious safety problems; the method was considered well tolerated by children. Therefore, TMS is a promising method: international experience (China, Europe, the USA) includes cases in which a course of rTMS reduced spasticity and improved motor skills in children with hemiparetic CP and even improved speech in diplegia. At present, TMS is not yet part of routine CP rehabilitation protocols, but within clinical trials and in specialized centers it is worth considering as an option, especially for patients with marked spasticity or dystonia that does not respond to medication.

Other Device-Based Methods and Rehabilitation Technologies

In addition to the brain stimulation methods discussed above, various engineering and device-based technologies are used in CP rehabilitation:

• Robotic locomotor therapy (exoskeletons, robotic gait trainers) – special devices that help a child practice walking by supporting the legs and moving them. In theory, they make it possible to repeat correct movements many times and stimulate neuroplasticity. However, the evidence of effectiveness is rather contradictory. A meta-analysis of 8 RCTs (188 patients) showed that stationary robotic gait systems do NOT exceed standard physical therapy in effect: there was no statistically significant difference between robotic training and regular exercise in the 6-minute walk test, walking speed, or GMFM scores (standing and walking/running/jumping). The researchers concluded that treadmill-based exoskeletons do not produce greater improvement in mobility than traditional rehabilitation. At the same time, another review that included a wider range of studies (including uncontrolled ones) noted positive changes: improved walking distance, GMFM scores, and endurance after a course of robotic therapy. In other words, robotic devices can indeed improve gait parameters, but a similar effect can also be achieved with properly organized physical therapy. Currently, robotic systems (such as Lokomat) are used as part of comprehensive rehabilitation in leading centers, especially for children who cannot walk independently, to maintain motor activity. But they are not approved as a standard method with a proven advantage over physical therapy. One example of modern robotic technology is wearable exoskeletons for correcting abnormal gait. In the USA (NIH), a prototype pediatric exoskeleton was created for treating crouch gait in children with CP. This external orthosis with sensors and motors supports knee extension at the right phases of the step. In a clinical study, most children aged 5–19 who used the exoskeleton were able to increase knee extension by up to 37° and improve their gait pattern. Thus, new exoskeleton systems may become a useful supplement for correcting specific gait problems, although they require further evaluation in long-term trials.
• Virtual reality (VR) and gaming technologies – interactive computer programs that stimulate movement in a game format (for example, balance games, hand coordination games, and the use of Wii or Kinect sensors for rehabilitation). In recent years, substantial evidence has accumulated that VR therapy improves motor function in children with CP. A systematic review of 19 RCTs (2017) showed a large overall effect of VR compared with conventional rehabilitation methods (pooled effect size d≈0.86). A particularly large effect was noted for arm function (d≈0.84) and postural control and balance (d≈1.00); a moderate effect was seen for gait function (d≈0.76). Children who completed a course of VR games showed better progress in fine motor skills, reaction speed, standing stability, and so on, compared with those who received only traditional physical exercise. Although the studies were heterogeneous (they used both commercial game consoles and specially developed VR systems) and the samples were relatively small, the overall conclusion is that VR is a useful addition to CP rehabilitation. This method increases children's motivation for therapy and provides a high volume of movement repetitions and feedback. That is why VR therapy is increasingly being introduced into rehabilitation programs for children with CP in international practice (USA, Europe). In Ukraine, this direction is also promising: implementation requires equipment (a computer, a VR headset, or a game console) and training of rehabilitation specialists in using game protocols.
• Functional electrical stimulation (FES) – the application of electrical impulses to peripheral nerves or muscles to trigger a muscle contraction or make movement easier. FES can be used, for example, to stimulate the foot dorsiflexor muscles during a step (to prevent foot slap) or to strengthen the trunk muscles. The evidence base for FES in CP has grown in recent years. A meta-analysis of 14 RCTs (421 children) showed that adding neuromuscular electrical stimulation to standard therapy led to higher walking speed and significantly better results in GMFM dimension E (standing, walking, running) compared with physical therapy alone. In particular, the gain in the "walking/running/jumping" dimension had an effect size of SMD≈1.24 (95% CI 0.64–1.83), which is a large effect. Conclusion: electrical stimulation improves mobility in children with spastic CP and is safe when used correctly. In practice, FES is recommended to be used under the supervision of a physical therapist, either as training on equipment or through wearable stimulators (for example, a "peroneal nerve stimulator" to lift the foot during walking). This method is considered part of modern comprehensive rehabilitation.
  
• Other device-based methods. These include innovative approaches that are still at the research stage: for example, brain-computer interface (BCI) systems, which read brain signals and let the patient control a computer or robot with the power of thought. They are still experimental, but in the future they may help non-communicative children with severe paralysis interact with their environment. Likewise, deep brain stimulation (DBS) – surgical implantation of electrodes into the basal ganglia – is used in some centers to treat severe dystonia in CP. There are examples in which DBS in the globus pallidus reduced dystonic symptoms and improved quality of life in adolescents with CP, but there are few controlled trials, and it is an invasive and expensive method.
  

Summary of non-drug methods: The highest level of evidence is found for VR therapy, FES, and rTMS, which showed statistically significant benefits in meta-analyses. The general trend in international experience is to combine classical rehabilitation (physical therapy, occupational therapy, speech therapy) with new technologies that enhance training through neurostimulation or increased motivation. Such a multidisciplinary approach offers the best chance of progress for the child.

Pharmacological and Biological Methods

Drug Therapy for Spasticity and Associated Conditions

Drug treatment in CP is aimed mainly at relieving symptoms: reducing spasticity and dystonia, controlling epileptic seizures, reducing drooling, and so on. Over the past 20 years, improved regimens for known drugs and new pharmacological approaches have appeared.

Muscle relaxants and antispasmodics. The standard for systemic reduction of spasticity is baclofen (a GABA_B receptor agonist). Oral baclofen moderately reduces muscle tone but causes a sedative effect at high doses. An important advance was the introduction of the intrathecal baclofen pump – a device that is surgically implanted and continuously delivers baclofen into the cerebrospinal fluid. This allows a high drug concentration in the spinal cord with low systemic doses. Short-term RCTs showed that intrathecal baclofen significantly reduces spasticity in children with CP (compared with placebo). Improvement in GMFM was also observed in some patients, although data on the functional effect are less clear-cut. A Cochrane systematic review notes that intrathecal baclofen significantly improves muscle tone scores (on the modified Ashworth scale) in the short term. Overall, the level of evidence for intrathecal baclofen is moderate, and it is recommended for severe spasticity that is not controlled by oral medications.

To relieve local spasticity and muscle hypertonia, botulinum toxin type A is the drug of choice (BTA). Injections of BTA into spastic muscles (for example, the gastrocnemius in equinus foot, or the hip adductors in spastic scissoring of the legs) cause a temporary chemical denervation effect, relaxing the muscle. The effectiveness of botulinum toxin has been confirmed by numerous studies: according to pooled data from several meta-analyses, BTA effectively reduces spasticity in CP (standardized mean differences from -0.98 to -0.01 in favor of treatment). This is reflected in improved scores on the modified Ashworth scale (MAS) and increased passive range of motion in the joint. As a result, the patient's mobility and comfort improve, and hygiene procedures become easier. For example, injecting BTA into the hip adductor muscles reduces "scissor" gait and makes caring for the child easier. The effect begins after 1–2 weeks and lasts about 3–6 months, after which injections can be repeated. Botulinum toxin has a high level of evidence (Ia) and is included in all international protocols for treating spasticity in CP. In addition, BTA is used to correct arm spasticity to improve grasp function: injections into the wrist and finger flexor muscles have been shown to improve the quality of arm movements and bimanual skills in children.

In addition to baclofen and BTA, other muscle relaxants are used when needed: diazepam (effective but limited by sedation and dependence), tizanidine, and dantrolene (used less often because of its effect on the liver). For dystonia, trihexyphenidyl (an anticholinergic drug) is used: in studies, ~60% of children with the dystonic form had improved tone and motor control on high doses of trihexyphenidyl, although side effects (dry mouth, drowsiness) are not uncommon. In severe dystonia, levodopa may also be considered, mainly to differentiate from dopaminergic deficiencies (some forms of hereditary dystonia that resemble CP respond to levodopa).

Anticonvulsants. About 30–50% of children with CP have epileptic seizures. International experience in treating epilepsy in CP is the same as in pediatric epileptology in general: valproate, levetiracetam, topiramate, and others are used. Seizure control indirectly supports the child's cognitive development and learning, so optimal anticonvulsant therapy is a mandatory part of the protocol.

Other symptomatic medications. To reduce excessive drooling in children with CP (which improves quality of life and helps prevent aspiration), topical scopolamine (as a patch) or oral glycopyrrolate is used; there are also approaches with botulinum toxin injection into the parotid glands, which reduce salivation. For osteopenia/osteoporosis, which is common in severe CP because of limited movement, vitamin D and bisphosphonates are used (as recommended by an endocrinologist).

Thus, pharmacotherapy for CP is mainly aimed at improving quality of life and preparing the child for rehabilitation by relieving interfering symptoms. Botulinum toxin and baclofen (especially intrathecal) are methods with a high level of evidence for controlling spasticity. These methods are recommended by international guidelines (NICE, AAN, etc.) as part of the standard of care.

Gene Therapy

Classic CP is not a monogenic disease, so there is no direct "correction" of a gene defect as there is in hereditary diseases. However, about 10–15% of CP cases have a genetic basis (for example, mutations are found that lead to congenital brain abnormalities or metabolic diseases). This opens up potential for gene therapy in selected patients. In recent years, genetic engineering has achieved success in treating some neurological disorders in children: in particular, AADC (aromatic L-amino acid decarboxylase) deficiency, a rare genetic disease that often mimics the hyperkinetic form of CP, is now treated with gene therapy (the drug eladocagene exuparvovec, approved by the FDA in 2022). Delivery of a viral vector carrying the AADC gene into the brain restores dopamine synthesis and significantly improves motor function in such patients. Although this treatment applies not to CP itself but to a separate monogenic disease, the example of AADC deficiency demonstrates the fundamental possibility of gene therapy for severe movement disorders in children.

Scientists are also considering the potential of gene therapy for neuroprotection and regeneration. Experimental work in animal models of CP has shown that delivery of genes for neurotrophic factors or anti-apoptotic proteins may reduce brain damage. However, such approaches have not yet been tested in the clinic.

On the other hand, the 2012 Nobel achievement was the discovery of induced pluripotent stem cell (iPSC) technology, awarded for the work of Shinya Yamanaka. This technology makes it possible to reprogram ordinary somatic cells (for example, skin cells) of a patient into pluripotent stem cells and then differentiate them into the desired type (neurons, glial cells). Although this is not direct "gene therapy," iPSC technology is closely linked to genetic engineering and gives hope that in the future it may be possible to grow nerve cells from a patient's own cells and transplant them to replace damaged neurons. Importantly, iPSCs are autologous, so rejection would be avoided. This is one of the promising strategies arising from the Nobel-winning discovery, which could potentially change approaches to CP treatment in the future.

In summary, gene therapy is not yet widely used in CP, but the development of precise methods (CRISPR-Cas9, viral vectors) and successes in related conditions give hope. Experimental gene-therapy studies aimed at restoring the balance of neurotransmitters in the brain or protecting white matter are ongoing. As of today, gene therapy remains more of a theoretical option and a "ray of hope" for the future than a real part of the CP treatment protocol.

Cell Therapy (Stem Cell Transplantation)

Stem cells have been one of the hottest areas in the search for cerebral palsy treatment over the past 20 years. Various types of stem cells (hematopoietic, mesenchymal, embryonic, umbilical cord blood, etc.) have been tested with the aim of stimulating repair of the damaged brain or replacing lost neurons.

The mechanisms by which stem cells may help in CP include secretion of neurotrophic factors (which enhances plasticity and regeneration), modulation of the immune response, and, in part, potential differentiation into neurons or glia. Preclinical studies gave encouraging results. This led to numerous clinical trials around the world. As of 2020, about 39 clinical studies of stem cell therapy in CP had been registered (18 of them already completed).

The most studied approaches are umbilical cord blood transplantation (which contains hematopoietic and some stem cells) and administration of mesenchymal stem cells (MSCs) obtained from bone marrow or the umbilical cord. In most cases the cells were given intravenously; some studies used intrathecal administration (into the cerebrospinal fluid).

Several examples of notable studies:

• In the USA, a team at Duke University conducted an RCT of autologous umbilical cord blood infusion in children with CP. In this double-blind, placebo-controlled study, 63 children (aged 1–6 years) received a single infusion of their own cord blood at a dose of 10–50 million cells/kg, or placebo, with crossover after one year. After 1 year, the change in motor function (GMFM-66) was assessed and MRI tractography of the brain was performed. Result: in the group that received a high dose of cells (>20 million/kg), a significant improvement in overall motor function and improved connectivity of brain tracts were observed compared with placebo. The children gained better control of their movements, which was confirmed by objective methods. The study concluded that, at a sufficient dose, autologous cord blood improves gross motor function and brain connectivity in children with CP. This was one of the first pieces of evidence for the effectiveness of cell therapy from an RCT.
  
• In South Korea, several studies of allogeneic umbilical cord MSCs and combination therapy have been conducted. In one RCT, injections of cord MSCs + erythropoietin + rehabilitation were compared with rehabilitation alone in children with CP; after 6 months the MSC group had a greater gain in GMFM and a reduction in spasticity intensity.
  
• In China and India there are case series in which children received autologous bone marrow cells (mononuclear fraction) intrathecally. Improvements in muscle tone and some motor skills were reported, although the study designs often did not include a control group.
  

Systematic reviews of these clinical trials note that almost all studies report improvement in children's condition after stem cell therapy, especially in gross motor function and muscle tone. Importantly, no serious safety problems were identified: stem cell therapy is considered relatively safe with appropriate monitoring (temporary fever and headache are possible; isolated cases of seizures or infections are related to the lumbar puncture procedure).

However, differences between protocols are very large: different cell sources (umbilical cord, bone marrow, embryonic), different doses (from 10 million to several hundred million cells), and different routes of administration. There is no consensus on the optimal cell type and regimen. For example, one study showed that bone marrow mesenchymal stem cells were more effective than bone marrow mononuclear cells. Another observation is that the effect may fade over time, so repeated injections have been proposed to maintain a long-term result.

As of today, stem cells in CP treatment are an innovative approach. Most authors agree that stem cell therapy may have a therapeutic effect in CP (may improve children's condition), although the evidence is still limited.

In light of this, some countries (for example, the USA) run compassionate-use programs for umbilical cord blood: if a child has stored cord blood, an infusion may be given within a protocol. In Ukraine, cell therapy for CP is currently not standardized, but there are private projects and studies in which parents seek such treatment on their own initiative.

Emerging Pharmacological Approaches

In addition to traditional drugs, new medications are appearing on the horizon that target neuroplasticity and symptom relief in CP with fewer side effects. For example, in 2024 in Australia a phase I/II study of the drug NTI164 for spastic diplegia was launched. NTI164 is a cannabis extract from a special strain (it contains the cannabinoids CBDA, CBDP, CBC, etc. with minimal THC). The idea is to improve muscle tone and the child's comfort without the marked sedation that is typical of standard anti-spasticity drugs. The NTI164 study will evaluate the effect of a 12-week course on spasticity, pain, sleep, and motor function in children who cannot walk independently. The developers hope that NTI164 will become a breakthrough option for treating spasticity, with improved gross motor function and quality of life, because current medications often cause drowsiness, confusion, and other undesirable effects. Although the results of this trial are not yet known, the fact of the study itself reflects a global trend: the search for new molecules for CP therapy, from neuroprotectors to cannabinoids and neuromodulators.

Another direction is the use of neurotrophic and neurometabolic drugs. In some countries (in particular, post-Soviet ones), nootropics and cerebroprotectors (cerebrolysin, Actovegin, etc.) are popular for CP, but Western standards do not confirm their effectiveness in controlled trials, so the level of evidence for such prescriptions is low. In contrast, the use of erythropoietin (EPO) and magnesium sulfate is more promising, but at the prevention stage: studies suggest that giving EPO to newborns with hypoxic-ischemic encephalopathy or to very preterm infants may reduce the risk of developing CP later (these are preventive strategies, which have also become an achievement of the past 20 years).

Thus, pharmacology for CP is developing in two directions: improving symptomatic agents (to better control spasticity/dystonia with fewer side effects) and the search for disease-modifying interventions (neuroprotection, stimulation of repair, which are still at the research stage). New technologies, such as genetically engineered proteins, cannabinoids, and antibodies to inhibitors of neuronal growth, may in the future add to the arsenal of CP treatment.

International Experience and Success Stories

Treating CP is a complex task that requires a multidisciplinary approach. International experience indicates that the best results are achieved by combining several methods, selected individually for the child, starting from an early age and continuing throughout childhood.

USA and Canada. These countries have well-developed early intervention programs: as soon as a diagnosis is established (and often already when CP is suspected in an infant), the child is enrolled in physical therapy and occupational therapy programs, and parents are trained in care skills. Botulinum toxin injections are widely used to prevent contractures and improve the possibilities for physical rehabilitation. The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) publishes guidelines and "Care Pathways," which are algorithms for managing patients. For example, for spastic diplegia with preserved walking, the recommended approach is a course of intensive physical therapy (the LEMS or TheraSuit method), botulinum toxin into the calf muscles every 6 months if needed, and ankle-foot orthoses (AFOs). If these are not effective, the child is referred for selective dorsal rhizotomy (surgical cutting of some nerve rootlets, which aims to reduce spasticity long-term). There are well-known success stories in which a combination of multilevel orthopedic surgery and intensive rehabilitation allowed teenagers with CP to begin walking with support. In the area of biological methods, the USA is a leader in cord blood research: as mentioned, at Duke University there were cases in which an infusion of the child's own cord blood markedly improved motor skills (according to the study leader, children began to control the head better, sit, and even stand with support). These success stories stimulate further research.

Europe. In EU countries, CP rehabilitation is well structured: there are early intervention centers and specialized rehabilitation clinics. In Germany, Sweden, and France, modern technical aids are actively being introduced: children regularly train on robotic trainers and VR systems. European researchers have also contributed to the evidence base: for example, French scientists were among the first to conduct a large RCT of hyperbaric oxygen therapy and showed that it was not effective. In the United Kingdom there is a national program to provide children with CP with communication devices and computer aids (so that even non-speaking children can communicate through eye gaze or button presses). The Netherlands and the Scandinavian countries are known for their success in integrating children with CP into society: education and sports (the Paralympic movement). In terms of medication, the same agents (BTA, baclofen) are approved in Europe; some countries also allow medical cannabis for treating spasticity in children when traditional drugs do not help.

Asia. In China, South Korea, and India there is great interest in stem cells. Chinese clinics report thousands of cases treated with MSC therapy, though often without proper oversight. In South Korea, some clinics officially perform umbilical cord blood transplantation for children with CP, and the state invests in research in this area. In India there are several published series (up to 100 patients) with autologous bone marrow therapy, in which a significant proportion of patients showed improvement (especially at under 3 years of age). In Japan and Singapore, genetic engineering studies are underway (in Japan, in particular, work is under way on methods for transplanting iPSC-derived cells).

Success stories are often published as descriptions or local studies. For example, a case was recently described of a teenager with severe dystonic CP who, after implantation of a DBS neurostimulator, was able to substantially reduce involuntary movements and use a computer (similar cases appear in the literature, although the method is still experimental). Another reported case is a child with CP who took part in a combined therapy program: 30 sessions of rTMS + intensive physical therapy + electrical stimulation moved from GMFCS level IV to level III in a year (began to sit independently and stand with support). Such isolated examples show that the combined use of new methods may contribute to progress in a child's development.

For the exchange of experience, international conferences are held (for example, the "International Child Neurology Congress"), where new approaches are discussed. It should also be noted that Nobel achievements influence this field indirectly: the discovery of nerve growth factors (Rita Levi-Montalcini, Nobel Prize 1986) became the basis for research into neurotrophic therapies, the discovery of iPSCs (Nobel Prize 2012) gave an impetus to cell therapy, and research on brain plasticity (Nobel laureates of the 2000s–2010s) contributed to the development of neurorehabilitation methods.

The Ukrainian context: In Ukraine there are specialists and centers that are adopting this experience. Botulinum toxin is already used (widely in regional rehabilitation centers), intrathecal pumps are implanted (some neurosurgical departments install them, although so far only occasionally), and children have access to physical therapy and exercise therapy using modern methods. Private clinics offer a hyperbaric chamber, but given the evidence base this should not be recommended as a mandatory method. Instead, it is worth introducing VR rooms and play rooms with therapeutic software, and purchasing locomotor trainers. Ukrainian scientists (for example, the Institute of Genetic and Regenerative Medicine) also conduct research on stem cells in CP. It is important to integrate into international clinical trials so that our patients have access to advanced technologies.

Recommendations and Cerebral Palsy Treatment Protocol

Based on the analysis of evidence-based methods, a structured clinical protocol for the rehabilitation of children with CP can be formulated. It provides for a multidisciplinary approach, gradual introduction of effective interventions, and monitoring of results. A step-by-step plan is given below:

1. Early detection and assessment. As soon as CP is diagnosed or suspected in a child (preferably before 1 year of age), the child is placed under the care of a multidisciplinary team. The team includes a neurologist or physiatrist, a physical therapist (rehabilitation specialist), an occupational therapist, a speech therapist, an orthopedist, and a psychologist. A comprehensive examination is performed: assessment of motor function (GMFM-66 scales, GMFCS level), muscle tone (MAS), presence of contractures, and assessment of swallowing, hearing, vision, and cognitive development. Individual rehabilitation goals are set together with the family. The family is given information about CP, the prognosis, and possible methods of help. It is very important to start early intervention: stimulation of the infant's motor development through play, massage, positioning, and training parents in therapeutic care (for example, the Bobath concept or Vojta therapy for infants).
2. Basic rehabilitation therapy. The basis of CP treatment is non-drug rehabilitation, so a continuous program of sessions is prescribed from the moment of diagnosis:

• Physical therapy (exercise therapy): individual sessions 2–5 times a week aimed at improving head control, rolling over, sitting, crawling, and walking, depending on age and abilities. Methods used include NDT Bobath and intensive programs such as CME (the Castillo-Morales method). For older children, elements of sports activity, swimming, and hippotherapy where possible.
• Occupational therapy: development of self-care skills, fine motor skills, and hand manipulation. Use of a hand splint if there is a tendency toward an adducted position, and grasp training through play tasks.
• Speech therapy and cognitive stimulation: the speech therapist begins working with the child as early as possible, even if the child does not yet speak (stimulation of understanding, gesture communication). A psychologist or special educator conducts sessions to develop cognitive functions and social skills.
• Orthoses and assistive devices: selection of orthopedic devices: night splints on the lower legs to prevent equinus, seating with trunk support for athetosis, and walkers or a parapodium for standing. Provision of a wheelchair, hand orthoses, etc., when necessary. This increases mobility and helps prevent deformities.
• Family-centered approach: parents are trained in exercises and positioning and include therapeutic exercises in daily care. Psychological support for the family and involvement in communities of parents of children with CP.

Stage 2 is a constant background: these interventions continue throughout childhood, with the program adjusted according to the child's progress.

3. Drug treatment of spasticity and other medical problems. In parallel with rehabilitation, the doctor assesses the need for medications:

• If the child has marked generalized spasticity that interferes with movement or care, oral baclofen is prescribed (gradual dose increase to an effective dose, monitoring for drowsiness). If it is not effective enough or causes side effects, diazepam at night may be added or the drug may be replaced with tizanidine.
• For local spastic deformities (for example, a very short Achilles tendon due to spasticity of the triceps surae), botulinum toxin injections into these muscles are planned. Botulinum therapy is performed by a doctor trained in it (an orthopedist or rehabilitation specialist), approximately at the age of 2–4 years, when spasticity begins to cause contractures. After the injection, intensive stretching and exercises, casting, or wearing an orthosis to maintain the achieved range of motion are mandatory. The cycle is repeated every 3–6 months if needed. This may help avoid the need for early orthopedic surgery.
• If there is dystonia or athetosis, a course of trihexyphenidyl is considered, with gradual dose escalation. A trial course of 2–3 months is given and the effect is assessed (whether movement control has improved and the pathological postural pattern has decreased). If the effect is positive, treatment continues; if there is none, it is discontinued.
• Anticonvulsant drugs: prescribed immediately when epilepsy is diagnosed, taking the type of seizures into account. The goal is full seizure control, because uncontrolled epilepsy worsens the rehabilitation prognosis.
• Other symptomatic treatment: as indicated, treatment of gastroesophageal reflux (common in CP, PPIs are needed), nutritional support (feeding tubes or a gastrostomy for severe swallowing disorders), and drooling medications as mentioned above.

4. Surgical and injection interventions if needed. At a certain stage (mostly at 4–8 years), orthopedic problems are assessed: hip subluxation (a common complication in spastic paraparesis), fixed contractures, and spinal deformities. A team of orthopedists and neurosurgeons together with rehabilitation specialists makes a decision:

• Orthopedic surgery: when necessary, open tendon lengthening (Achilles, adductor muscles), corrective osteotomies of bones for hip dislocation, spinal fusion for severe scoliosis, and so on. Such interventions are carried out for absolute indications (when conservative measures have been exhausted) in specialized centers, preferably as multilevel surgery (to correct several problems at once and reduce the number of operations).
• Selective dorsal rhizotomy (SDR): in children with spastic diplegia GMFCS II–III (who walk with support), aged ~3–6 years, SDR may be considered: a neurosurgeon cuts some of the sensory rootlets L2–S1 that lead to spastic leg muscles. This aims to reduce spasticity long-term, makes physical therapy easier, and may improve range of motion. There are selection criteria (good muscle strength, spasticity predominating over dystonia). If the child meets the criteria, he or she is referred to a neurosurgery center for SDR. After the operation, intensive rehabilitation for 6–12 months follows. It has been shown that in selected cases SDR may improve walking function and reduce the need for orthopedic operations.
• Intrathecal baclofen pump: for children with generalized spasticity GMFCS IV–V who do not walk but have painful muscle spasms, or for whom care is very difficult, it is appropriate to consider a baclofen pump. If the center has this capability, a trial injection of baclofen into the spinal canal is performed and the reduction in tone is assessed. If the effect is good, the system is implanted. After that, the child is followed by the pump team (dose adjustment, pump refill about every 3 months). This may significantly improve comfort for the patient and caregivers.
• Botulinum toxin therapy: continues to be given periodically if focal areas of spasticity remain after other interventions, or in new muscle groups (for example, in the upper limbs; in spastic diplegia, problems with facial expression or chewing may arise, and BTA can be considered there as well).

5. Integration of new technologies into the rehabilitation program. Depending on the clinic's capabilities and the patient's condition, supplementary methods with demonstrated effectiveness are added gradually:

• Virtual reality and computer games: if the clinic has a VR system or a game console with rehabilitation software, the child takes part in such sessions 1–2 times a week. Goals: improve balance (through balance board or Kinect games), stimulate arm movements ("catch the object" type games), and train walking speed (a virtual track). Session length is 20–30 minutes. Tasks are made gradually more difficult. VR therapy can be introduced from 4–5 years of age, when the child is able to interact with the game. Progress should be tracked with quantitative metrics (for example, a line-walking test or the Timed Up and Go test before and after the course).
• Biofeedback: where EMG biofeedback equipment is available, include biofeedback sessions 2 times a week, for example to train relaxation of antagonist muscles during movement or to teach activation of weak muscles. It is particularly useful for walking: teaching the child to extend the hip or knee more actively by showing the signal from the relevant muscles on a screen. Biofeedback courses should be 10–15 sessions followed by a break.
• Transcranial stimulation (TMS/tDCS): if equipment and specialists are available, these methods can be introduced as part of the program. For example, tDCS: 20-minute sessions of anodal stimulation of the motor cortex immediately before or during physical therapy sessions, in a course of 10–15 sessions. rTMS: courses of non-invasive magnetic stimulation (for example, 10 sessions of low-frequency rTMS over cortical areas associated with the spastic limb), with subsequent testing of tone and movement. For now, these procedures should be introduced mainly within research protocols or as individual treatment with parental consent, because they are new. Changes must be documented (GMFM scores, video recordings of motor skills before and after).
• Functional electrical stimulation: recommended for broad use in the clinic. For example, daily during physical therapy, use portable stimulators on the foot dorsiflexor muscles, knee extensors, and elbow flexors, depending on which muscle groups are weak. Also consider FES cycling equipment (an ergometer with electrical stimulation), where the child trains the legs even if unable to turn the pedals independently, because stimulation produces movement and the muscles work.
• Robotics: if a Lokomat or other robotic trainers are available, include them 2–3 times a week as a supplement to traditional therapy. Make sure that robotic therapy does not displace active exercises but is part of the overall program. The robot is mainly useful for children who cannot perform the correct movement on their own, helping them feel the pattern. But children who can walk with minimal support are better encouraged to be independently active with physical assistance than to rely entirely on an exoskeleton.
• Cell therapy: not yet part of the standard in Ukraine, but if parents are interested after a detailed discussion of the benefits and risks, infusion of autologous cord blood may be considered at the age of 1–3 years, which studies suggest may be the most favorable period. Perform it only in an institution that has experience and authorization for such procedures. After the cells are given, rehabilitation is intensified, with assessment at 3, 6, and 12 months by GMFM, video analysis, and so on.
• New drugs/protocols: track the appearance of new medications (for example, cannabinoids) in Ukraine or neighboring countries. If cannabidiol-based drugs become officially available for children, their off-label use can be discussed with parents for severe spasticity that does not respond to other treatments. Dosing and monitoring should follow epilepsy protocols (since cannabidiol is approved for treating epilepsy in children, its profile is known).

6. Monitoring progress and adjusting the plan. The protocol provides for regular assessment of achievements and problems:

• Every 6 months, hold a multidisciplinary case conference for the patient: compare GMFM scores, assess new skills (whether the child has started sitting, walking with support, etc.), and review goals. If necessary, adjust the individual plan (for example, if the child has achieved sufficient head control, the next goal is to teach independent sitting; if a contracture has developed, add stretching work or plan surgery).
• Keep documentation and a video archive: short videos of key motor skills once a year, to track progress objectively and show parents progress or problems.
• Assess tolerance of interventions: whether there are side effects from medications (adjust doses if necessary) and whether the child is overloaded with sessions (avoid "burnout": rehabilitation should be intensive but manageable and interesting for the child).

7. Transition to adolescence and adult life. The protocol should include planning for long-term support. In adolescence the emphasis shifts: more attention to social adaptation, career guidance, and maximum development of independence. If any method was not used in childhood but could help an adolescent (for example, DBS for severe dystonia), consider it at this stage as well. Ensure continuity when transferring the patient to the adult care network (adult rehabilitation specialists, employment centers for people with disabilities, etc.).

Organizational Aspects of Implementing the Protocol

For successful implementation of the described protocol in clinical practice, the following is needed:

• Staff training: training rehabilitation teams in modern methods. Training sessions for physical therapists on VR therapy and biofeedback, and for doctors on botulinum therapy, pump management, and tDCS/TMS. Involving experienced mentors (possibly from abroad) to improve qualifications.
• Material and technical base: equipping rehabilitation centers with the necessary equipment. At a minimum: exercise therapy rooms, parallel bars for walking, orthoses, and a pool or baths for hydrotherapy. Where possible, acquiring modern systems: at least one VR set, an EMG biofeedback device, a TMS stimulator (if trained staff are available), and an FES device/ergometer. Equipping a hyperbaric chamber is not a priority because of its questionable effectiveness.
• Interdisciplinary cooperation: establishing regular case conferences of neurologists, orthopedists, and rehabilitation specialists. Developing unified criteria for referral to surgery or intensive protocols (so that all specialists speak "the same language" about indications).
• Patient-centered care: involving parents in therapy planning and taking their wishes into account. Providing educational materials in Ukrainian about all methods (brochures, leaflets about botulinum toxin, home care, alternative communication, etc.).
• Evaluating the effectiveness of implementation: collecting statistics on results in the clinic's own practice (for example, what percentage of children started sitting at age 2 or walking at age 5), comparing them with international figures, and adjusting approaches if needed. Publishing its own observations in scientific journals, thereby contributing to world experience.

Conclusion: Modern CP treatment is a combination of time-tested methods (rehabilitation, orthopedic correction, medications) with innovative technologies (neurostimulation, VR, cell therapy). Each method should be evaluated from the standpoint of evidence-based medicine: introduce what has confirmed effectiveness, and experiment cautiously with new approaches within scientific protocols. For Ukraine, the optimal strategy is to adopt the best world practices, adapting them to our resources. CSM Clinic uses modern approaches and innovative treatment methods, contributing to the standardization of care for children with CP, improving its effectiveness, and improving the quality of life of patients and their families.

Author: O. S. Kiian
Founder and Director of CSM Clinic

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