Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy

A consensus statement on the use of botulinum toxin in pediatric patients

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

Effect of botulinum toxin type-A in spasticity and functional outcome of upper limbs in cerebral palsy

INTRODUCTION

Spasticity has been considered to be a main contributor to both the impairment of function as well as posture in children with cerebral palsy (CP). Patterns of upper limb motor involvement in CP vary with resultant limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is a potent neurotoxin which acts by preventing the release of acetylcholine (Ach) from presynaptic axon at motor end plate reducing focal spasticity. With literature established role of BTX-A available for lower limb spasticity in CP, the purpose of this study was to present an objective analysis of the effect of a single i.m. injection of BTX-A in reduction of spasticity in the upper limb as well as functional outcome in children (4-12yrs) with spastic CP.

METHODS

A total of 28 patients (30 upper limbs) of spastic CP with minimum follow up of 6months were included in the study. Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were used to measure the spasticity. Surface landmarks were used to give I.m. Botox in selected spastic muscles followed by targeted rehabilitation. Functional outcomes were measured by MACS (Manual Ability Classification System) and Canadian Occupational Performance Measure (COPM) before treatment, at 3 and 6 months follow up.

RESULTS

Pronator teres was the most frequently injected muscle followed by FCU and Adductor pollicis. MAS scores at all joints and MTS scores at forearm deteriorated between 3 and 6 months. However, MACS and COPM showed sustained improvement at 3months and 6months with statistically significant change.

CONCLUSION

I.m. BTX-A injected using anatomical landmarks had significant improvement in both clinical and functional outcome measures. We noticed significant improvement in MACS and COPM at 6 months despite return of local spasticity. It is safe and effective for spasticity of upper limbs in cerebral palsy and capable of improving function without major side effects. MACS & COPM are easy to use, less time consuming & easily adjusted to local needs. Randomized control trials with long follow up are required in future with special focus on dosing and timing, scoring system for functional outcome as per regional needs and issue for antibody formation for repeat injections of BTX-A.

Reliability of Inclinometer-Derived Passive Range of Motion Measures in Youth with Cerebral Palsy

Aims: This study evaluated, for youth with cerebral palsy (CP), the reliability of passive range of motion (PROM) measures taken with an inclinometer, a device that may be simpler to use than a goniometer. Methods: The PROM for elbow and wrist extension, ankle dorsal flexion (knee flexed 90° and fully extended), and the knee popliteal angle of 30 youth with CP (18 boys, 12 girls, 7.0 ± 3.8 years old, classified in Gross Motor Function Classification levels I-V) was measured using an inclinometer. Two physical therapists took the measures during two different sessions, a maximum of 1 week apart. Results: Good mean intra-rater inter-session, inter-rater intra-session, and inter-rater inter-session reliability (ICC = 0.75-0.89), was found for the elbow, ankle, and knee sites. Absolute reliability for these sites and conditions was 7-14° (90% confident) and 10-16° (95% confident). Reliability values for wrist extension were comparable, albeit slight lower. Conclusions: Similar to published values for goniometry, inclinometery yields reliable upper and lower limb PROM measures from ambulatory and non-ambulatory youth with CP whether measures are carried out by different evaluators within or across sessions or whether measures are performed by the same evaluator across sessions.

The Future of Upper Extremity Spasticity Management

Surgical management of upper limb spasticity has traditionally tackled the downstream effects at the muscle, tendon, and joint levels. Because this approach does not address the underlying pathologic condition within the nerve, surgical outcomes have been marked by unsatisfactory relapse over time. Future management may focus on reestablishing a normal neuronal impulse pathway to the dysfunctional musculotendinous unit. By severing the faulty γ-neuronal circuit at the C7 level, spasticity may be reduced. Transfer of the contralateral C7 nerve root to the injured C7 nerve root may open the potential for simultaneously restoring extension and improving reach and grasp functions.

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

Objective: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy.

Methods: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis.

Results: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) ( n = 64) of high methodological quality, and nine uncontrolled studies ( n = 107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities.

Conclusion: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.

Spastic Paralysis of the Elbow and Forearm

As the physiologic recovery period concludes, the patient is evaluated for surgical procedures that may rebalance muscle function and correct deformity. Upper extremity function is the product of complex and highly sophisticated mechanisms working in unison, and a careful, systematic preoperative evaluation is critical. A good function of the hand cannot be achieved without adequate position of the shoulder, elbow, forearm, and wrist. The goals of surgery must be practical and clearly understood by the patient and the family.

Functional electrical stimulation combined with botulinum toxin type A to improve hand function in children with spastic hemiparesis - a pilot study

BACKGROUND

Children with spastic hemiparesis frequently present with impaired hand function due to paresis, spasticity, and disturbed motor control. The aim of this study was to examine the effectiveness of functional electrical stimulation in combination with botulinum toxin type A in these children.

DESIGN

Randomized, controlled, observer-blinded pilot study.

SUBJECTS

Children with impaired hand function.

INTERVENTIONS

Either a combined treatment group (functional electrical stimulation and botulinum toxin type A) or a botulinum toxin type A group alone. Botulinum toxin type A was injected into arm muscles according to the patient's clinical requirements. Functional electrical stimulation of the wrist and finger extensor muscles was started after five to six days. Patients were given a stimulation device and asked to use it at home twice daily for 15 min, for a total period of three months.

MAIN MEASURES

Active and passive range of motion, muscle tone, muscle strength, and functional tests for children.

RESULTS

Six children aged between 7 and 17 years with spastic hemiparesis were enrolled. In both groups, active and passive range of motion, muscle tone, and muscle strength improved after three and six months compared to baseline data. The functional score was improved only in the group that received combined treatment.

CONCLUSIONS

Combined treatment with functional electrical stimulation and botulinum toxin type A is a promising treatment option to improve upper limb function in children with spastic hemiparesis.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE)

BACKGROUND

Cerebral palsy (CP) is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbance that occurred in the developing fetal or infant brain" (Rosenbaum 2007, p.9). The spastic motor type is the most common form of CP. Therapeutic management may include splinting/casting, passive stretching, facilitation of posture/movement, spasticity-reducing medication and surgery. Botulinum toxin-A (BoNT-A) is now used as an adjunct to these techniques in an attempt to reduce spasticity, improve range of movement and function.

OBJECTIVES

To assess the effectiveness of injections of BoNT-A or BoNT-A and occupational therapy in the treatment of the upper limb in children with CP.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register/CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (1966 to August Week 1 2008), EMBASE (1980 to 2008 Week 28) and CINAHL (1982 to August Week 1 2008).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing BoNT-A injection or BoNT-A injection and occupational therapy in the upper limb(s) with other types of treatment (including no treatment or placebo) in children with CP.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity and rated for quality using the PEDro scale. Data were extracted and entered into RevMan 5.0.15.

MAIN RESULTS

Ten trials met the inclusion criteria. PEDro quality ratings ranged from 6/10 to 10/10. Concentration of BoNT-A ranged from 50U/1.0ml to 200U/1.0ml saline with doses of 0.5U to 16U/kg body weight and total doses of 220 to 410 Units (Botox(R)).A combination of BoNT-A and occupational therapy is more effective than occupational therapy alone in reducing impairment, improving activity level outcomes and goal achievement, but not for improving quality of life or perceived self-competence. When compared with placebo or no treatment, there is moderate evidence that BoNT-A alone is not effective.

AUTHORS' CONCLUSIONS

This systematic review found high level evidence supporting the use of BoNT-A as an adjunct to managing the upper limb in children with spastic CP. BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy.Further research is essential to identify children most likely to respond to BoNT-A injections, monitor longitudinal outcomes, determine timing and effect of repeated injections and the most effective dosage, dilution and volume schedules. The most effective adjunct therapies including frequency and intensity of delivery also requires investigation.

Systematic review and meta-analysis of therapeutic management of upper-limb dysfunction in children with congenital hemiplegia

CONTEXT

Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly.

OBJECTIVES

To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia.

METHODS

The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews.

RESULTS

Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale > or = 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score > or = 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes.

CONCLUSIONS

No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb-training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training.

Neurologic uses of botulinum neurotoxin type A

This article reviews the current and most neurologic uses of botulinum neurotoxin type A (BoNT-A), beginning with relevant historical data, neurochemical mechanism at the neuromuscular junction. Current commercial preparations of BoNT-A are reviewed, as are immunologic issues relating to secondary failure of BoNT-A therapy. Clinical uses are summarized with an emphasis on controlled clinical trials (as appropriate), including facial movement disorders, focal neck and limb dystonias, spasticity, hypersecretory syndromes, and pain.

Upper-limb botulinum toxin A injection and occupational therapy in children with hemiplegic cerebral palsy identified from a population register: a single-blind, randomized, controlled trial

OBJECTIVES

The purpose of this work was to assess the effect of botulinum toxin A and occupational therapy compared with occupational therapy alone on body structure, activities participation, and self-perception in a sample of children (aged 3-16 years) with hemiplegic cerebral palsy recruited from a statewide register.

PATIENTS AND METHODS

Participants of this single-blind, randomized, controlled trial identified from a population-based cerebral palsy register received either an individually prescribed and localized injection of botulinum toxin A with 4 sessions of occupational therapy over 4 weeks (intervention) or occupational therapy alone (control). Outcomes were assessed from 2 domains of the World Health Organization International Classification of Functioning, Disability, and Health: body structure (Modified Ashworth Scale and Tardieu Scale) and activities participation (Assessment of Motor and Process Skills, Goal Attainment Scale, Pediatric Evaluation of Disability Inventory, and Pediatric Quality of Life Inventory). Self-perception was also measured.

RESULTS

All of the participants (intervention: n = 21; control: n = 22) provided data at baseline and 3 and 6 months. Mean age was 8.6 years; 23 were boys and 20 were girls. At 3 months, children allocated to receive the intervention performed significantly better in terms of body structure and activities participation. They reported improvements in self-perception for the global self-worth domain. At 6 months, the differences between the intervention and control groups persisted for the measures of body structure but not for activities participation or self-perception.

CONCLUSION

Botulinum toxin A injection combined with a low-intensity occupational therapy program achieves significant improvements in body structure, activity participation, and self-perception.

Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy

BACKGROUND

Children with hemiplegic cerebral palsy learn strategies to manage daily tasks (for example play) using one hand and often the affected limb is disregarded or not used. Constraint-induced movement therapy (CIMT) is emerging as a treatment approach for use with children with hemiplegic cerebral palsy. It aims to increase spontaneous use of the affected upper limb and thereby limit the effects of developmental disregard. CIMT is based on two fundamental principles: constraint of the non-affected limb and massed practice of therapeutic tasks with the affected limb.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of CIMT, modified CIMT or Forced Use in the treatment of the affected upper limb in children with hemiplegic cerebral palsy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to August Week 4 2006), CINAHL (1982 to July Week 3 2006), EMBASE (1980 to August 2006), PsychInfo (1985 to August Week 4 2006) and reference lists of all relevant articles.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing CIMT, modified CIMT and Forced Use with traditional services such as occupational therapy, physiotherapy or no treatment were selected.

DATA COLLECTION AND ANALYSIS

Two review authors extracted the data independently using standardised forms. Each trial was assessed for internal validity with differences in ratings resolved by discussion. Data were extracted and entered into Review Manager 4.2 where appropriate.

MAIN RESULTS

Three studies met the inclusion criteria. The results of one RCT showed a trend for positive treatment effect favouring CIMT using the Dissociated Movement subscale of the Quality of Upper Extremity Skills Test (QUEST). Other outcome measures, that were without reported psychometric properties, showed significant treatment effects. A CCT demonstrated a significant treatment effect favouring modified CIMT at two and six months using the Assisting Hand Assessment (AHA). Another trial with inaccurate reporting and ambiguous methodology, showed a significant treatment effect at 6 weeks on the self care component of the WeeFIM using a Forced Use protocol. All other measures showed no significant treatment effect.

AUTHORS' CONCLUSIONS

This systematic review found a significant treatment effect using modified CIMT in a single trial. A positive trend favouring CIMT and Forced Use was also demonstrated. Given the limited evidence, the use of CIMT, modified CIMT and Forced Use should be considered experimental in children with hemiplegic cerebral palsy. Further research using adequately powered RCTs, rigorous methodology and valid and reliable outcome measures is essential to provide higher level support of the effectiveness of CIMT for children with hemiplegic cerebral palsy.

Functional outcomes of intramuscular botulinum toxin type a and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial

OBJECTIVE

To investigate the functional outcomes of botulinum toxin type A (BTX-A) injections to the upper limb in combination with occupational therapy (OT) in children with cerebral palsy (CP).

DESIGN

Randomized controlled trial with follow-up at 2 weeks, 3 months, and 6 months.

SETTING

Specialist outpatient physical disabilities clinic within a public pediatric teaching hospital.

PARTICIPANTS

Eighty children with spastic quadriplegic, triplegic, or hemiplegic CP from these clinics were randomly assigned to BTX-A plus OT, BTX-A alone, OT alone, or a no-treatment control group.

INTERVENTIONS

Single set of BTX-A (Botox) injections and 12 weeks of OT.

MAIN OUTCOME MEASURES

Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS).

RESULTS

The combination of BTX-A and OT resulted in accelerated attainment of functional goals measured by the COPM and GAS. There were no differences between groups on the Melbourne Assessment of Unilateral Upper Limb Function, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Child Health Questionnaire, or active and passive range of motion. As expected, there was a significant reduction in muscle tone at follow-up 2 weeks after injection, which returned to baseline level by 6 months.

CONCLUSIONS

OT enhanced individualized functional outcomes following BTX-A injections in the upper limbs of children with CP.

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.