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Gill R, Banky M, Yang Z, Medina Mena P, Woo CCA, Bryant A, Olver J, Moore E, Williams G. The Effect of Botulinum Neurotoxin-A (BoNT-A) on Muscle Strength in Adult-Onset Neurological Conditions with Focal Muscle Spasticity: A Systematic Review. Toxins (Basel) 2024; 16:347. [PMID: 39195757 PMCID: PMC11359732 DOI: 10.3390/toxins16080347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/28/2024] [Accepted: 08/05/2024] [Indexed: 08/29/2024] Open
Abstract
Botulinum neurotoxin-A (BoNT-A) injections are effective for focal spasticity. However, the impact on muscle strength is not established. This study aimed to investigate the effect of BoNT-A injections on muscle strength in adult neurological conditions. Studies were included if they were Randomised Controlled Trials (RCTs), non-RCTs, or cohort studies (n ≥ 10) involving participants ≥18 years old receiving BoNT-A injection for spasticity in their upper and/or lower limbs. Eight databases (CINAHL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Pubmed, Web of Science) were searched in March 2024. The methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in the Prospective Register of Systematic Reviews (PROSPERO: CRD42022315241). Quality was assessed using the modified Downs and Black checklist and the PEDro scale. Pre-/post-injection agonist, antagonist, and global strength outcomes at short-, medium-, and long-term time points were extracted for analysis. Following duplicate removal, 8536 studies were identified; 54 met the inclusion criteria (3176 participants) and were rated as fair-quality. Twenty studies were analysed as they reported muscle strength specific to the muscle injected. No change in agonist strength after BoNT-A injection was reported in 74% of the results. Most studies' outcomes were within six weeks post-injection, with few long-term results (i.e., >three months). Overall, the impact of BoNT-A on muscle strength remains inconclusive.
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Affiliation(s)
- Renée Gill
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
- School of Physiotherapy, The University of Melbourne, Parkville, Melbourne 3000, Australia (A.B.)
| | - Megan Banky
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
- School of Physiotherapy, The University of Melbourne, Parkville, Melbourne 3000, Australia (A.B.)
| | - Zonghan Yang
- School of Physiotherapy, The University of Melbourne, Parkville, Melbourne 3000, Australia (A.B.)
| | - Pablo Medina Mena
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
| | - Chi Ching Angie Woo
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
| | - Adam Bryant
- School of Physiotherapy, The University of Melbourne, Parkville, Melbourne 3000, Australia (A.B.)
| | - John Olver
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
| | - Elizabeth Moore
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
| | - Gavin Williams
- Department of Physiotherapy, Epworth Rehabilitation Epworth Healthcare Richmond, Melbourne 3121, Australia; (M.B.); (P.M.M.); (C.C.A.W.); (J.O.); (E.M.); (G.W.)
- School of Physiotherapy, The University of Melbourne, Parkville, Melbourne 3000, Australia (A.B.)
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2
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Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JP. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses. BMJ Open 2024; 14:e076675. [PMID: 38195174 PMCID: PMC10810041 DOI: 10.1136/bmjopen-2023-076675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVES This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured. DESIGN Systematic review of systematic reviews (umbrella review). DATA SOURCES Cochrane Database of Systematic Reviews. ELIGIBILITY CRITERIA Systematic reviews attempt to compare surgical to drug interventions. DATA EXTRACTION We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review. SYNTHESIS The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed. RESULTS Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance. CONCLUSIONS Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.
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Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Denmark, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John P Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
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3
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Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JPA. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.30.23285207. [PMID: 36778340 PMCID: PMC9915830 DOI: 10.1101/2023.01.30.23285207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored. Design Systematic review of systematic reviews (umbrella review). Data sources Cochrane Database of Systematic Reviews (CDSR). Eligibility criteria and synthesis of results Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses. Results Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs. Conclusions Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed. Protocol registration https://osf.io/p9x3j.
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Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherland, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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CARRANZA-DEL RÍO J, DURSUN N, CEKMECE C, BONIKOWSKI M, PYRZANOWSKA W, DABROWSKI E, TILTON A, OLESZEK J, VOLTEAU M, PAGE S, SHIERK A, DELGADO MR. Goal Attainment after Treatment with Abobotulinumtoxina and a Tailored Home Therapy Programme in Children with Upper Limb Spasticity: Descriptive, Exploratory Analysis of a Large Randomized, Controlled Study. J Rehabil Med 2022; 54:jrm00349. [PMID: 36306168 PMCID: PMC9762673 DOI: 10.2340/jrm.v54.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This exploratory analysis of a large, randomized, double-blind study (NCT02106351) describes the effect of treatment with abobotulinumtoxinA followed by a tailored home exercises therapy programme in enabling children with upper limb spasticity due to cerebral palsy to achieve their functional goals using goal attainment scaling (GAS). METHODS Children with cerebral palsy and spasticity in ≥ 1 upper limb received up to 4 injection cycles of abobotulinumtoxinA (2 U/kg (cycle 1 only), 8U/kg and 16U/kg) into the elbow and wrist flexors and other upper limb muscles selected to support individual treatment goals. Children followed a home exercises therapy programme, which included stretches and exercises specifically chosen to facilitate goal achievement and engagement in activities. RESULTS For cycle 1, most children had active function goals set as their primary goal (69.7% vs 19.2% passive function goals). GAS T- scores and goal responder rates at week 16 indicated that most types of primary goal were achieved at least as expected during cycle 1 (all groups). Primary goal GAS T-scores were generally maintained for the first 3 abobotulinumtoxinA treatment cycles. CONCLUSION Most children with upper limb spasticity treated with repeat cycles of abobotulinumtoxinA supported by an individualized home exercises therapy programme achieved their functional goals.
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Affiliation(s)
| | - Nigar DURSUN
- Kocaeli University Faculty of Medicine Department of Physical Medicine and Rehabilitation, Turkey
| | - Cigdem CEKMECE
- Kocaeli University Faculty of Medicine Department of Physical Medicine and Rehabilitation, Turkey
| | | | | | - Edward DABROWSKI
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI
| | - Ann TILTON
- LSU Health Sciences Center and Children’s Hospital New Orleans, New Orleans, LA
| | | | | | | | - Angela SHIERK
- University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Mauricio R. DELGADO
- University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, USA
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Gantelius S, Vikerfors S, Edqvist JJ, von Walden F, Hagströmer M, Pontén E. Time-matched accelerometers on limbs and waist in children with CP give new insights into real-life activities after botulinum toxin treatment: A proof of concept study. J Pediatr Rehabil Med 2022; 16:125-137. [PMID: 36314229 PMCID: PMC10116137 DOI: 10.3233/prm-210112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
PURPOSE This study aimed to explore the feasibility of using time-matched uniaxial accelerometers for measuring movement in daily life in children with cerebral palsy (CP) before and after botulinum toxin injections. METHODS This observational study of clinical care with a pre-post design was set in the home and school environment. Participants included eleven children (4-13 years of age) with CP (GMFCS I-III). The children wore uniaxial accelerometers (ActiGraph, model GT1M) for 4 days on both wrists, the right ankle and around the waist before, 3 weeks and 3 months after BoNT-A injections in the legs. Five children also got BoNT-A in the most affected arm. All injections were given according to clinical indications and routine. The accelerometers were all time-matched to define ambulation, arm swing, voluntary activity of arms, and bimanual activity. The feasibility of wearing accelerometers with this setup was evaluated. A linear mixed model was used for analysis of the percentage time and at which intensity the different activities were performed. The confidence interval demonstrated any difference between the dominant and non-dominant arm. RESULTS Time-matching of accelerometers placed on both wrists, the waist, and one ankle is a feasible method of registering ambulation, arm swing during gait, and arm movements while not ambulating. Before injections, the children spent 5.6% of their time ambulating. This value declined to 3.9% at 3 months. Contrary to clinical goals, arm movement did not increase after injecting the most affected arm with BoNT-A, however, injections may have decreased mirror movements, which are often bothersome for the child. CONCLUSION A time-matched 4-accelerometer set-up is feasible in children with cerebral palsy. A future study including time-matched multi-axial accelerometers on all four limbs, could provide important information on the effect of BoNT-A in daily life.
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Affiliation(s)
- Stefan Gantelius
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Orthopaedic Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Vikerfors
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Örebro University Hospital, Örebro, Sweden
| | | | - Ferdinand von Walden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Maria Hagströmer
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Eva Pontén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Orthopaedic Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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6
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Dursun N, Akyuz M, Gokbel T, Akarsu M, Yilmaz E, Karacan C, Dursun E. GMFCS level improvement in children with cerebral palsy treated with repeat botulinum toxin injections and intensive rehabilitation: A retrospective study. J Pediatr Rehabil Med 2022; 15:107-112. [PMID: 35275571 DOI: 10.3233/prm-210013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The Gross Motor Functional Classification System (GMFCS) provides a standardized classification of motor disability in children with cerebral palsy (CP) that is typically considered longitudinally stable. Here, changes in GMFCS levels of children with CP who received repeated botulinum toxin A (BoNT-A) injections within an intensive rehabilitation approach were evaluated. METHODS This retrospective, observational study included 503 children with CP (GMFCS I-V) treated in a single university rehabilitation clinic. Individualized treatment plans and a variety of rehabilitation techniques were incorporated within an integrated model of care. Each child received≥2 repeated BoNT-A injections as well as an intensive rehabilitation program. RESULTS GMFCS level following repeat treatment improved in 42.1% of the patients and worsened in 3 patients; 14.9% of children showed improvement after 1 treatment cycle, 12.3% after 2 cycles, 7.6% after 3 cycles, 3.6% after 4 cycles, and 3.8% after≥5 cycles. Type of involvement (p < 0.001), baseline GMFCS (p = 0.001), number of treatment cycles (p < 0.001) and presence of severe dystonia (p = 0.032) were significant predictors of GMFCS improvement, but age and gender were not. CONCLUSION Children with CP may change GMFCS level when intensive rehabilitation programs are combined with repeated BoNT-A injections.
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Affiliation(s)
- Nigar Dursun
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Merve Akyuz
- Bursa State Hospital Department of Physical Medicine and Rehabilitation, Bursa, Turkey
| | - Tugba Gokbel
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Melike Akarsu
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Esin Yilmaz
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Cagla Karacan
- Gedik University Faculty of Sports Sciences, Istanbul, Turkey
| | - Erbil Dursun
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
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Kaňovský P, Heinen F, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Martinez-Torres FJ, Pulte I, Banach M, Gaebler-Spira D. Safety and efficacy of repeat long-term incobotulinumtoxinA treatment for lower limb or combined upper/lower limb spasticity in children with cerebral palsy. J Pediatr Rehabil Med 2022; 15:113-127. [PMID: 34957963 PMCID: PMC9028655 DOI: 10.3233/prm-210041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The open-label phase 3 "Treatment with IncobotulinumtoxinA in Movement Open-Label" (TIMO) study investigated longer-term safety and efficacy of incobotulinumtoxin A in children/adolescents with cerebral palsy (CP). METHODS Patients on standard treatment, with unilateral or bilateral lower limb (LL) or combined upper limb (UL)/LL spasticity received four incobotulinumtoxinA injection cycles (16 or 20 Units/kg bodyweight total [maximum 400 or 500 Units] per cycle depending on ambulatory status/clinical pattern treated), each followed by 12-16 weeks' observation. Treatment for pes equinus was mandatory; flexed knee or adducted thigh were options for unilateral treatment and/or ULs for unilateral/bilateral treatment. The primary endpoint was safety; changes in Ashworth Scale and Gross Motor Function Measure-66 scores, and Global Impression of Change Scale scores at week 4 of each injection cycle were also evaluated. RESULTS IncobotulinumtoxinA (≤500 Units for ≤98 weeks) was safe, well-tolerated, and effective across all endpoints for multipattern treatment of LL and combined LL/UL spasticity in ambulant/nonambulant children/adolescents with CP. Treatment effects increased with each injection cycle. No new/unexpected safety concerns were identified. CONCLUSION IncobotulinumtoxinA showed a good safety and tolerability profile, with efficacy over multiple clinical presentations. As an adjunct treatment, it offers an effective, individualized treatment option for pediatric CP-related spasticity.
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Affiliation(s)
- Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Florian Heinen
- Department of Pediatric Neurology & Developmental Medicine and LMU Center for Children with Medical Complexity, Dr.von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - A Sebastian Schroeder
- Department of Pediatric Neurology & Developmental Medicine and LMU Center for Children with Medical Complexity, Dr.von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, MI, USA
| | | | | | | | - Irena Pulte
- Merz Pharmaceuticals Gmb H, Frankfurt am Main, Germany
| | - Marta Banach
- Department of Neurology, Collegium Medicum, Jagiellonian University, Krakow, Poland
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Oleszek J, Tilton A, Carranza Del Rio J, Dursun N, Bonikowski M, Dabrowski E, Page S, Regnault B, Thompson C, Delgado MR. Muscle Selection and Dosing in a Phase 3, Pivotal Study of AbobotulinumtoxinA Injection in Upper Limb Muscles in Children With Cerebral Palsy. Front Neurol 2021; 12:728615. [PMID: 34803878 PMCID: PMC8603760 DOI: 10.3389/fneur.2021.728615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Guidelines recommend botulinum toxin-A in pediatric upper limb spasticity as part of routine practice. Appropriate dosing is a prerequisite for treatment success and it is important that injectors have an understanding on how to tailor dosing within a safe and effective range. We report upper limb dosing data from a phase 3 study of abobotulinumtoxinA injections in children with cerebral palsy. Methods: This was a double-blind, repeat-treatment study (NCT02106351). In Cycle 1, children were randomized to abobotulinumtoxinA at 2 U/kg control dose or clinically relevant 8 U/kg or 16 U/kg doses. Doses were divided between the primary target muscle group (PTMG, wrist or elbow flexors) and additional muscles tailored to clinical presentation. During Cycles 2–4, children received doses of 8 U/kg or 16 U/kg and investigators could change the PTMG and other muscles to be injected. Injection of muscles in the other upper limb and lower limbs was also permitted in cycles 2–4, with the total body dose not to exceed 30 U/kg or 1,000 U (whichever was lower) in the case of upper and lower limb treatment. Results: 212 children were randomized, of which 210 received ≥1 abobotulinumtoxinA injection. Per protocol, the elbow and wrist flexors were the most commonly injected upper limb muscles. Across all 4 cycles, the brachialis was injected in 89.5% of children (dose range 0.8–6 U/kg), the brachioradialis in 83.8% (0.4–3 U/kg), the flexor carpi ulnaris in 82.4% (0.5–3 U/kg) and the flexor carpi radialis in 79.5% (0.5–4 U/kg). Other frequently injected upper limb muscles were the pronator teres(70.0%, 0.3–3 U/kg). adductor pollicis (54.3%, 0.3-1 U/kg), pronator quadratus (44.8%, 0.1–2 U/kg), flexor digitorum superficialis (39.0%, 0.5-4 U/kg), flexor digitorum profundus (28.6%, 0.5–2 U), flexor pollicis brevis/opponens pollicis (27.6%, 0.3-1 U/kg) and biceps (27.1%, 0.5–6 U/kg). AbobotulinumtoxinA was well-tolerated at these doses; muscular weakness was reported in 4.3% of children in the 8 U/kg group and 5.7% in the 16 U/kg group. Conclusions: These data provide information on the pattern of injected muscles and dose ranges used in this study, which were well-tolerated. Per protocol, most children received injections into the elbow and wrist flexors. However, there was a wide variety of other upper limb muscles injected as physicians tailored injection patterns to clinical need.
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Affiliation(s)
- Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, University of Colorado and Children's Hospital Colorado, Aurora, IL, United States
| | - Ann Tilton
- LSUHSC and Children's Hospital New Orleans, New Orleans, LA, United States
| | | | - Nigar Dursun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kocaeli University, Izmit, Turkey
| | | | - Edward Dabrowski
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI, United States
| | | | | | | | - Mauricio R Delgado
- Southwestern Medical Center, Scottish Rite Hospital for Children, University of Texas, Dallas, TX, United States
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9
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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10
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Delgado MR, Tilton A, Carranza‐Del Río J, Dursun N, Bonikowski M, Aydin R, Maciag‐Tymecka I, Oleszek J, Dabrowski E, Grandoulier A, Picaut P. Efficacy and safety of abobotulinumtoxinA for upper limb spasticity in children with cerebral palsy: a randomized repeat-treatment study. Dev Med Child Neurol 2021; 63:592-600. [PMID: 33206382 PMCID: PMC8048784 DOI: 10.1111/dmcn.14733] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
AIM To assess the efficacy and safety of repeat abobotulinumtoxinA injections in reducing upper limb spasticity in children with cerebral palsy (CP). METHOD This was a double-blind, repeat-cycle study (NCT02106351) in children with CP (2-17y). Children were randomized to receive 2U/kg (control), 8U/kg, or 16U/kg abobotulinumtoxinA injections into the target muscle group (wrist or elbow flexors) and additional muscles alongside occupational therapy via a home-exercise therapy program (HETP; minimum five 15min sessions/wk). Children received 8U/kg or 16U/kg plus HETP in cycles 2 to 4. RESULTS During cycle 1, 210 children (126 males, 84 females; mean age [SD] 9y [4y 5mo], range 2-17y; n=70/group) had at least one upper limb abobotulinumtoxinA injection and 209 complied with the HETP. At week 6 of cycle 1, children in the 8U/kg or 16U/kg groups had significantly lower Modified Ashworth scale scores versus the 2U/kg group (primary outcome: treatment differences of -0.4 [p=0.012] and -0.7 [p<0.001] respectively). All groups improved on Physician Global Assessment and children in all groups achieved their treatment goals at least as expected. Therapeutic benefits were sustained during cycles 2 to 4; muscular weakness was the only treatment-related adverse event reported in at least one child/group (4.3% and 5.7% vs 1.4% respectively). INTERPRETATION Treatment with 8U/kg or 16U/kg abobotulinumtoxinA significantly reduced upper limb spasticity versus the 2U/kg control dose. Therapeutic benefits of abobotulinumtoxinA plus HETP were sustained with repeat treatment cycles. WHAT THIS PAPER ADDS AbobotulinumtoxinA injections significantly reduced upper limb spasticity in children with cerebral palsy. Children treated with abobotulinumtoxinA and targeted home exercises showed global improvement and goal attainment. Benefits were sustained over 1 year with repeat cycles of abobotulinumtoxinA and home exercises. AbobotulinumtoxinA injections into the upper limb were well tolerated over 1 year.
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Affiliation(s)
- Mauricio R Delgado
- Department of NeurologyUniversity of Texas Southwestern Medical CenterScottish Rite Hospital for ChildrenDallasTXUSA
| | - Ann Tilton
- Department of NeurologyLSUHSC and Children's Hospital New OrleansNew OrleansLAUSA
| | | | - Nigar Dursun
- Department of Physical Medicine and RehabilitationFaculty of MedicineKocaeli UniversityKocaeliTurkey
| | | | - Resa Aydin
- Department of Physical Medicine and RehabilitationIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | | | - Joyce Oleszek
- Department of Physical Medicine and RehabilitationUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Edward Dabrowski
- Department of Pediatric Physical Medicine and RehabilitationBeaumont HealthOakland University School of MedicineGrosse PointeMIUSA
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Complex ventral hernia repair in a child: An association of botulinum toxin, progressive pneumoperitoneum and negative pressure therapy. A case report on an arising surgical technique. Int J Surg Case Rep 2021; 81:105828. [PMID: 33887832 PMCID: PMC8027269 DOI: 10.1016/j.ijscr.2021.105828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 01/13/2023] Open
Abstract
Giant omphalocele establish a therapeutic challenge to the surgeon - mainly because of the increased visceroabdominal disproportion and underlying malformations - and the best approach is still debatable worldwide. This is the second report on the literature and states the management of a child born with giant omphalocele that developed a very complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect. It seems that the use of botulinum toxin agents in the abdominal wall is safe and effective in children with giant omphaloceles and it eliminates the use of a mesh even in more difficult cases. This technique seems safe and effective and it should be encouraged and best evaluated. It is time to start defining better criteria to categorize giant omphalocele in order to choose the best management for each patient.
Introduction The purpose of this manuscript is to report the management of a child born with giant omphalocele (GO) that developed a complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect. Presentation of case The patient underwent a one-step surgery to correct a ventral hernia associated with a largely prolapsed enteroatmospheric fistula (EAF) along with an ileostomy. It was managed by a pre-operative association of botulinum toxin agent (BTA) application with preoperative progressive pneumoperitoneum (PPP) and trans-operative negative pressure wound therapy (NPWT) dressing with staged abdominal closure. The patient needed 4 reoperations due to enteric fistulas. Nine days after the first surgery, it was possible to completely close the abdominal wall without mesh substitution. No signs of hernia in 9 months of follow-up. Discussion This is the second report in the literature and it reinforces the safety and effectiveness of the BTA injection associated with PPP in children. Conclusion The use of BTA in association with PPP should be encouraged and best investigated in patients with GO. The fistulas were not attributed to the negative pressure. Maybe it is time to start defining better criteria to categorize GO in order to choose the best management for each patient.
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Patel AT, Wein T, Bahroo LB, Wilczynski O, Rios CD, Murie-Fernández M. Perspective of an International Online Patient and Caregiver Community on the Burden of Spasticity and Impact of Botulinum Neurotoxin Therapy: Survey Study. JMIR Public Health Surveill 2020; 6:e17928. [PMID: 33284124 PMCID: PMC7752537 DOI: 10.2196/17928] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 08/05/2020] [Accepted: 10/20/2020] [Indexed: 01/13/2023] Open
Abstract
Background Patient- and caregiver-reported data are lacking on the burden of spasticity, and the impact of botulinum neurotoxin type A (BoNT-A) treatment for this condition, on patients' daily lives. As recommended in recent guidance from the US Food and Drug Administration, online patient communities can represent a platform from which to gather specific information outside of a clinical trial setting on the burden of conditions experienced by patients and caregivers and their views on treatment options in order to inform evidence-based medicine and drug development. Objective The objective of our study is to characterize spasticity symptoms and their associated burdens on Western European and US patients and caregivers in the realms of work, daily activities, quality of life (QoL), as well as the positive and negative impacts of treatment with BoNT-A (cost, time, QoL) using Carenity, an international online community for people with chronic health conditions. Methods We performed a noninterventional, multinational survey. Eligible participants were 18 years old or older and had, or had cared for, someone with spasticity who had been treated with BoNT-A for at least 1 year. Patients and caregivers were asked to complete an internet-based survey via Carenity; caregivers reported their own answers and answered on behalf of their patients. Questions included the burden of spasticity on the ability to work, functioning, daily-living activities, and QoL, the impact of BoNT A therapy on patients' lives, and the potential benefits of fewer injections. Results There were 615 respondents (427 patients and 188 caregivers). The mean age of patients and caregivers was 41.7 years and 38.6 years, respectively, and the most commonly reported cause of spasticity was multiple sclerosis. Caregivers were most often the parents (76/188, 40%) or another family member (51/188, 27%) of their patients. Spasticity had a clear impact on patients' and caregivers' lives, including the ability to work and injection costs. For patients, spasticity caused difficulties with activities of daily living and reduced QoL indices. The median number of BoNT-A injections was 4 times per year, and 92% (393/427) of patients reported that treatment improved their overall satisfaction with life. Regarding the BoNT-A injection burden, the greatest patient-reported challenges were the cost and availability of timely appointments. Overall, 86% (368/427) of patients believed that a reduced injection frequency would be beneficial. Caregivers answering for their patients gave largely similar responses to those reported by patients. Conclusions Spasticity has a negative impact on both patients' and caregivers' lives. All respondents reported that BoNT A treatment improved their lives, despite the associated challenges. Patients believed that reducing the frequency of BoNT-A injections could alleviate practical issues associated with treatment, implying that a longer-acting BoNT-A injection would be well received.
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Affiliation(s)
- Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS, United States
| | - Theodore Wein
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Laxman B Bahroo
- Department of Neurology, Georgetown University, Georgetown, DC, United States
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Peck J, Urits I, Kassem H, Lee C, Robinson W, Cornett EM, Berger AA, Herman J, Jung JW, Kaye AD, Viswanath O. Interventional Approaches to Pain and Spasticity Related to Cerebral Palsy. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:108-120. [PMID: 33633421 PMCID: PMC7901135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose of Review This review will cover seminal and emerging evidence on interventional therapy chronic pain in cerebral palsy (CP). It will cover the background and burden of disease, present the current options, and then weigh the evidence that is available to support interventional therapy and the current indications. Recent Findings CP is a permanent posture and movement disorder from in-utero brain development defects with a 3-4/1,000 incidence in the US. The cost of care for each child is estimated at $921,000. Pain in CP is attributed to musculoskeletal deformities, spasticity, increased muscle tone, dislocations, and GI dysfunction. First-line treatments include physical and occupational therapy and oral pharmacological agents; however, a significant amount of patients remain refractory to these and require further therapy. Injection therapy includes botulinum toxin A (BTA) injections and intrathecal baclofen. BTA injections were shown to control chronic pain effectively and are FDA approved for spastic pain; intra-thecal baclofen, in contrast, was only shown to improve comfort and quality of life with a focus on the pain. Surgical intervention includes selection dorsal rhizotomy (SDR). It may increase range of motion and quality of life and reduce spasticity and pain; however, most evidence is anecdotal, and more research is required. Summary Interventional therapy, including injection and surgical, is the last line of therapy for chronic pain in CP. It extends the possibility of therapy in hard-to-treat individuals; however, more data is required to provide strong evidence to the efficacy of these treatments and guide proper patient selection.
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Affiliation(s)
- Jacquelin Peck
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Ivan Urits
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Hisham Kassem
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Christopher Lee
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Wilton Robinson
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Elyse M Cornett
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Amnon A Berger
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jared Herman
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jai Won Jung
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Alan D Kaye
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Omar Viswanath
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
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Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
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Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
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Fathi M, Hussein AS, M Elghazaly S, Al-Kinawy AM, Abdeltawab AK, Mansour YM, Elbehbeh NA, Sherif A, Afifi AM. Effect of Botulinum Toxin on Equinus Foot Deformity in Cerebral Palsy Patients: A Systematic Review and Network Meta-analysis. Curr Pharm Des 2020; 26:4796-4807. [PMID: 32418518 DOI: 10.2174/1381612826666200518105633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is a brain disorder that affects the development, movement and posture leading to limitation of Range of Movement (ROM) in the growing children. CP leads to deformities such as equinus foot deformity. We aim to investigate the efficacy of different botulinum toxin (BTX) products with or without serial casting in reducing the muscle spasticity in equinus foot deformity in patients with CP. METHODS A systematic review of the literature was performed by searching different electronic databases. Pub- Med, Scopus, Web of Science (WOS), and GHL databases were used. We analyzed the extracted data by network meta-analysis method using the R software package (version 3.5.0). RESULTS Regarding Modified Ashworth score (MAS), BTX-A was superior compared to placebo and BTX-A plus immediate casting (MD = -0.39, 95% CI [-0.60; -0.18]) and (MD = -0.50, 95% CI [-0.98; -0.02]), respectively. Concerning growth motor function movement Classification System (GMFM), Neuronox ranked above at 3 months (MD = -1.60, 95% CI [-2.87; -0.33]) and at six months (MD = -1.90, 95% CI [-3.48; -0.32]) compared to BTX-A. Regarding the Modified Tardieu scale (MTS) with knee flexion, BTX-A was superior to BTX-A plus immediate casting (MD = 8.60, 95% CI [1.76; 15.44]). Concerning passive range of movement (PROM) with Knee flexion or extension at 3 months, BTX-A showed a significant improvement compared to BTX-A plus immediate casting. CONCLUSION BTX-A ranked best on a physician rating scale (PRS), MAS, MTS with knee flexion and PROM (Knee flexion and extension) compared to Neuronox and Botulax. BTX-A alone was also better than BTX-A plus immediate casting.
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Affiliation(s)
| | | | | | | | | | | | | | - Ahmed Sherif
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed M Afifi
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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16
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Jensen DB, Klingenberg S, Dimintiyanova KP, Wienecke J, Meehan CF. Intramuscular Botulinum toxin A injections induce central changes to axon initial segments and cholinergic boutons on spinal motoneurones in rats. Sci Rep 2020; 10:893. [PMID: 31964988 PMCID: PMC6972769 DOI: 10.1038/s41598-020-57699-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/30/2019] [Indexed: 01/29/2023] Open
Abstract
Intramuscular injections of botulinum toxin block pre-synaptic cholinergic release at neuromuscular junctions producing a temporary paralysis of affected motor units. There is increasing evidence, however, that the effects are not restricted to the periphery and can alter the central excitability of the motoneurones at the spinal level. This includes increases in input resistance, decreases in rheobase currents for action potentials and prolongations of the post-spike after-hyperpolarization. The aim of our experiments was to investigate possible anatomical explanations for these changes. Unilateral injections of Botulinum toxin A mixed with a tracer were made into the gastrocnemius muscle of adult rats and contralateral tracer only injections provided controls. Immunohistochemistry for Ankyrin G and the vesicular acetylcholine transporter labelled axon initial segments and cholinergic C-boutons on traced motoneurones at 2 weeks post-injection. Soma size was not affected by the toxin; however, axon initial segments were 5.1% longer and 13.6% further from the soma which could explain reductions in rheobase. Finally, there was a reduction in surface area (18.6%) and volume (12.8%) but not frequency of C-boutons on treated motoneurones potentially explaining prolongations of the after-hyperpolarization. Botulinum Toxin A therefore affects central anatomical structures controlling or modulating motoneurone excitability explaining previously observed excitability changes.
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Affiliation(s)
- D B Jensen
- Department of Neuroscience, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - S Klingenberg
- Department of Neuroscience, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - K P Dimintiyanova
- Department of Neuroscience, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - J Wienecke
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Nørre Allé 51, DK-2200, Copenhagen, Denmark
| | - C F Meehan
- Department of Neuroscience, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200, Copenhagen, Denmark.
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Valentine J, Davidson SA, Bear N, Blair E, Paterson L, Ward R, Forbes D, Elliott C. A prospective study investigating gross motor function of children with cerebral palsy and GMFCS level II after long-term Botulinum toxin type A use. BMC Pediatr 2020; 20:7. [PMID: 31906902 PMCID: PMC6945782 DOI: 10.1186/s12887-019-1906-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to contribute to the knowledge base on the long-term outcomes of evidence-based medical interventions used to improve gross motor function in children and adolescents with Cerebral Palsy. METHOD Prospective cohort study of children with Cerebral Palsy in the birth years 2000-2009 attending a tertiary level service for children with Cerebral Palsy who's first recorded Gross Motor Function Classification System level was II. RESULTS A total of 40 children were eligible for the study, of whom 28 (72.7%) enrolled. The Botulinum toxin A treatment for this cohort, (median and interquartile ranges) were: total number of lower limb Botulinum toxin A injections 11 (6.7, 5.5); total dose of Botulinum Toxin A per lower limb treatment 6.95 u/kg (4.5, 11); and dose of Botulinum Toxin u/kg/muscle 2.95 (2.2, 4). For all 28 subjects there was a median of 15 (8.5 to 22) Gross Motor Function Classification System level recordings: six of the 28 children (21.4%) improved from level II to level I, the remaining 22 children remained stable at level II (78.6%). In this highly treated population, the average 66 item Gross Motor Function Measure score for the 22 children in level II was 72.55, which is consistent with the mean of 68.5 reported in the original Ontario cohort. CONCLUSION This cohort study has confirmed that children with Cerebral Palsy, Gross Motor Function level II treated at a young age with repeated doses of Botulinum Toxin A within an integrated comprehensive service, maintain or improve their functional motor level at a later age.
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Affiliation(s)
- Jane Valentine
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia. .,Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia.
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Nedlands, Western Australia, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Lisa Paterson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| | - David Forbes
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia
| | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
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Kim HJ, Park JW, Nam K. Effect of extracorporeal shockwave therapy on muscle spasticity in patients with cerebral palsy: meta-analysis and systematic review. Eur J Phys Rehabil Med 2020; 55:761-771. [PMID: 31615195 DOI: 10.23736/s1973-9087.19.05888-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Recently, clinical trials have been performed to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) in patients with cerebral palsy (CP). However, various studies adopted different clinical scales, making it insufficient to draw a definite conclusion about the efficacy of ESWT in reducing spasticity after cerebral palsy. The purpose of this meta-analysis was to assess the effects of ESWT on reducing spasticity after applying ESWT in patients with CP. EVIDENCE ACQUISITION In accordance with the PRISMA statement, authors searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and Scopus from their inception dates through December 11th 2018. We included randomised controlled trials in any language that using ESWT for the purpose of ameliorating spasticity in patients with CP. We assessed spasticity measured by modified Ashworth Scale (MAS), range of motion (ROM) and baropodometric values as outcomes. EVIDENCE SYNTHESIS Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesised narratively. From a total of 206 articles, 16 manuscripts were selected and 5 of them were ultimately included in this meta-analysis. MAS grade as primary outcome was significantly improved after ESWT compared to that in the control group (mean difference [MD]: -0.62; 95% CI: -1.52 to -0.18). ROM after ESWT was also significantly improved compared to that in the control groups (MD: 18.01; 95% CI: 6.11 to 29.91). Baropodometric measures showed significantly increases in foot contact area during gait (SMD: 29.00; 95% CI: 11.08 to 46.92), but not significantly in peak pressure under the heel (MD: 15.12; 95% CI: -1.85 to 32.10) immediately after ESWT. CONCLUSIONS No serious side effects were observed in any patient after ESWT. ESWT may be a valid alternative to existing treatment options targeting spasticity diminishment and ROM improvement in CP patients to maintain healthy lifestyles and normalize spastic gait pattern. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow-up studies are needed to verify our results.
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Affiliation(s)
- Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jin-Woo Park
- Department of Physical Medicine and Rehabilitation, Dongguk University College of Medicine, Goyang, South Korea
| | - Kiyeun Nam
- Department of Physical Medicine and Rehabilitation, Dongguk University College of Medicine, Goyang, South Korea -
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Kurenkov A, Kuzenkova L, Fisenko D, Klochkova O, Bursagova B, Chernikov V. Changes of the spasticity patterns in children with cerebral palsy GMFCS III at the age of 2 to 12 years. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:36-44. [DOI: 10.17116/jnevro202012006136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Rombaldi MC, Neto WFS, Holanda FC, Cavazzola LT, Fraga JC. Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum. Hernia 2019; 24:1397-1400. [PMID: 31858310 DOI: 10.1007/s10029-019-02084-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
Abstract
Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.
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Affiliation(s)
- M C Rombaldi
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil.
| | - W F S Neto
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
| | - F C Holanda
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
| | - L T Cavazzola
- Department of General Surgery, Hospital de Clínicas, Porto Alegre, Brazil
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - J C Fraga
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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Kantor J, Kantorová L, Marečková J, Peng D, Vilímek Z. Potential of Vibroacoustic Therapy in Persons with Cerebral Palsy: An Advanced Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3940. [PMID: 31623221 PMCID: PMC6843730 DOI: 10.3390/ijerph16203940] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/17/2022]
Abstract
Vibroacoustic therapy (VAT) is a treatment method that uses sinusoidal low-frequency sound and music. The purpose of this narrative review is to describe the effects of VAT on motor function in people with spastic cerebral palsy (CP) according to study design as well as providing information about the age of the participants, measurement tools, and sound frequencies that were used. The systematic search strategy based on the first two steps of a standard evidence-based approach were used: (1) formulation of a search question and (2) structured documented search including assessment of the relevance of abstracts and full texts to the search question and inclusion criteria. Out of 823 results of the search in 13 scholarly databases and 2 grey literature sources, 7 papers were relevant. Most of the relevant studies in children and adults presented significant improvement of motor function. According to the study design, only five experimental studies and two randomized controlled trial (RCT) studies were available. In the discussion, findings of this review are compared to other related methods that use mechanical vibrations without music. The authors recommend continuing to research the effects of VAT on motor function and spasticity in adolescents and young adults with spastic CP.
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Affiliation(s)
- Jiří Kantor
- Institute of Special Education Studies, Faculty of Education, Palacky University Olomouc, Žižkovo nám. 5, 77900 Olomouc, Czech Republic.
| | - Lucia Kantorová
- Institute of Special Education Studies, Faculty of Education, Palacky University Olomouc, Žižkovo nám. 5, 77900 Olomouc, Czech Republic.
| | - Jana Marečková
- Department of Anthropology and Health Education, Faculty of Education, Palacky University Olomouc, Žižkovo nám. 5, 77900 Olomouc, Czech Republic.
| | - Danping Peng
- Institute of Education and Social Studies, Faculty of Education, Palacky University Olomouc, Žižkovo nám. 5, 77900 Olomouc, Czech Republic.
| | - Zdeněk Vilímek
- Institute of Special Education Studies, Faculty of Education, Palacky University Olomouc, Žižkovo nám. 5, 77900 Olomouc, Czech Republic.
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Plasschaert VFP, Vriezekolk JE, Aarts PBM, Geurts ACH, Van den Ende CHM. Interventions to improve upper limb function for children with bilateral cerebral palsy: a systematic review. Dev Med Child Neurol 2019; 61:899-907. [PMID: 30632139 PMCID: PMC6850353 DOI: 10.1111/dmcn.14141] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
AIM To systematically review the efficacy of interventions on upper limb function in children 0 to 19 years of age with bilateral cerebral palsy on the basis of outcome measures of upper limb function and measures of activities and/or participation according to the International Classification of Functioning, Disability and Health. METHOD Cochrane, PubMed, Embase, CINAHL, and Web of Science were searched from inception to September 2017. Methodological quality and strength of evidence were analysed by two independent raters using Sackett's level of evidence and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines. RESULTS Fifteen studies with a large variety of interventions and heterogeneity in outcome measures met the inclusion criteria. Twelve studies provided level IV evidence according to AACPDM guidelines. For three small randomized controlled trials the level of evidence was II. Only one of these trials showed strong methodological quality: a study on hand-arm bimanual intensive therapy including lower extremities. INTERPRETATION We identified a large variety of interventions, heterogeneity in outcome measures, and generally weak to moderate methodological quality for most studies. We recommend further research specifically aimed at bimanual-intensive, goal-directed, and task-specific training programmes for the upper limb in children with bilateral cerebral palsy, using either high-quality (multicentre) trials or well-designed single-case trials. WHAT THIS PAPER ADDS There is a large variety of interventions on upper limb function in children with bilateral cerebral palsy. Heterogeneity of outcome measures and interventions impeded firm conclusions about intervention efficacy. Most studies had low-level evidence and weak to moderate methodological quality. The strongest evidence from a small randomized controlled trial was for hand-arm bimanual intensive therapy including lower extremities.
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Affiliation(s)
- Véronique F P Plasschaert
- Department of Rehabilitation MedicineSint MaartenskliniekNijmegenthe Netherlands,Department of RehabilitationDonders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenthe Netherlands
| | | | - Pauline B M Aarts
- Department of Rehabilitation MedicineSint MaartenskliniekNijmegenthe Netherlands
| | - Alexander C H Geurts
- Department of Rehabilitation MedicineSint MaartenskliniekNijmegenthe Netherlands,Department of RehabilitationDonders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenthe Netherlands
| | - Cornelia H M Van den Ende
- Department of Rehabilitation MedicineSint MaartenskliniekNijmegenthe Netherlands,Department of RheumatologySint MaartenskliniekNijmegenthe Netherlands
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Novak I, Honan I. Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Aust Occup Ther J 2019; 66:258-273. [PMID: 30968419 PMCID: PMC6850210 DOI: 10.1111/1440-1630.12573] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Paediatric occupational therapy seeks to improve children's engagement and participation in life roles. A wide variety of intervention approaches exist. Our aim was to summarise the best-available intervention evidence for children with disabilities, to assist families and therapists choose effective care. METHODS We conducted a systematic review (SR) using the Cochrane methodology, and reported findings according to PRISMA. CINAHL, Cochrane Library, MEDLINE, OTSeeker, PEDro, PsycINFO were searched. Two independent reviewers: (i) determined whether studies met inclusion: SR or randomised controlled trial (RCT); an occupational therapy intervention for children with a disability; (ii) categorised interventions based on name, core components and diagnostic population; (iii) rated quality of evidence and determined the strength of recommendation using GRADE criteria; and (iv) made recommendations using the Evidence Alert Traffic Light System. RESULTS 129 articles met inclusion (n = 75 (58%) SRs; n = 54 (42%)) RCTs, measuring the effectiveness of 52 interventions, across 22 diagnoses, enabling analysis of 135 intervention indications. Thirty percent of the indications assessed (n = 40/135) were graded 'do it' (Green Go); 56% (75/135) 'probably do it' (Yellow Measure); 10% (n = 14/135) 'probably don't do it' (Yellow Measure); and 4% (n = 6/135) 'don't do it' (Red Stop). Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog-Fun & CAPS; CO-OP; CIMT; CIMT plus Bimanual; Context-Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task-Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss 'Mighty Moves'. CONCLUSION Evidence supports 40 intervention indications, with the greatest number at the activities-level of the International Classification of Function. Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.
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Affiliation(s)
- Iona Novak
- Cerebral Palsy AllianceDiscipline of Child and Adolescent HealthThe University of SydneyCamperdownNorth South WalesAustralia
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Rekand T, Biering-Sörensen B, He J, Vilholm OJ, Christensen PB, Ulfarsson T, Belusa R, Ström T, Myrenfors P, Maisonobe P, Dalager T. Botulinum toxin treatment of spasticity targeted to muscle endplates: an international, randomised, evaluator-blinded study comparing two different botulinum toxin injection strategies for the treatment of upper limb spasticity. BMJ Open 2019; 9:e024340. [PMID: 31061021 PMCID: PMC6502046 DOI: 10.1136/bmjopen-2018-024340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The therapeutic effects of botulinum neurotoxin (BoNT) are well documented in upper limb spasticity. However, several factors may influence treatment efficacy, including targeting of neuromuscular junctions (NMJs). We examined whether NMJ-targeted BoNT injections were non-inferior, in terms of efficacy, to current injection practices. DESIGN Open-label prospective evaluator-blinded study. SETTING Conducted across 20 medical centres in Denmark, Finland, Norway and Sweden (24 September 2012 to 11 March 2015). PARTICIPANTS Aged ˃18 years with upper limb spasticity (Modified Ashworth Scale [MAS] score of 2 or 3) following stroke or traumatic brain injury, had received ≥2 consecutive BoNT-A treatment cycles (the latest of which was abobotulinumtoxinA [aboBoNT-A]) and needed BoNT-A retreatment (same modality as previous cycle). Patients requiring aboBoNT-A doses >800units were excluded. In total, 88 patients were randomised (intention-to-treat [ITT] population), most were male (n=58/88, 65.9%) and 54/88 (61.4%) completed the study (per protocol [PP] population). INTERVENTIONS Randomisation (1:1) to receive a single dose of aboBoNT-A (≤800 U) according to either current clinical practice (300 U/mL) or as an NMJ-targeted injection (100 U/mL). PRIMARY OUTCOME MEASURE Proportion of patients with a ≥1 level reduction from baseline in MAS score at week 4 post-injection (responders). RESULTS In the ITT population, the proportion of responders at elbow flexors was 72.7% in the current practice group and 56.8% in the NMJ-targeted group (adjusted difference -0.1673 [95% CIs: -0.3630 to 0.0284]; p=0.0986). Similar results were observed in the PP population (69.0% vs 68.0%, respectively, adjusted difference 0.0707 [-0.1948 to 0.3362]; p=0.6052). CONCLUSIONS Owing to the limited number of participants, non-inferiority of NMJ-targeted injections could not be determined. However, there was no statistical difference between groups. Larger studies are needed confirm whether the two techniques offer comparable efficacy. TRIAL REGISTRATION NUMBER NCT01682148.
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Affiliation(s)
- Tiina Rekand
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Bo Biering-Sörensen
- Department of Neurology, Spasticity Clinic, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Jun He
- Department of Neurology, University Hospital of Copenhagen, Roskilde Sygehus, Denmark
| | | | | | - Trandur Ulfarsson
- Department of Rehabilitation Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Belusa
- Medical department, Institut Produits Synthese (AB), Stockholm, Sweden
| | - Torbjörn Ström
- Medical department, Institut Produits Synthese (AB), Stockholm, Sweden
| | - Peter Myrenfors
- Medical department, Institut Produits Synthese (AB), Stockholm, Sweden
| | - Pascal Maisonobe
- Medical department, Institut Produits Synthese (AB), Stockholm, Sweden
- Ipsen Innovation, Ipsen, Les Ulis, France
| | - Torben Dalager
- Clinic of Dystonia, Bispjeberg Hospital, Copenhagen, Denmark
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Hoare BJ, Wallen MA, Thorley MN, Jackman ML, Carey LM, Imms C. Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst Rev 2019; 4:CD004149. [PMID: 30932166 PMCID: PMC6442500 DOI: 10.1002/14651858.cd004149.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb. OBJECTIVES To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP. SEARCH METHODS In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors. MAIN RESULTS We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies. KEY RESULTS Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty. AUTHORS' CONCLUSIONS The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.
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Affiliation(s)
- Brian J Hoare
- Monash Children's HospitalVictorian Paediatric Rehabilitation Service246 Clayton RdClaytonVictoriaAustralia3168
| | - Margaret A Wallen
- Australian Catholic UniversitySchool of Allied Health, Faculty of Health SciencesNorth SydneyAustralia
| | - Megan N Thorley
- Royal Children's HospitalRehabilitationHerston RoadBrisbaneQueenslandAustralia4006
| | - Michelle L Jackman
- John Hunter Children's HospitalPaediatric Occupational TherapyLambton RoadNew LambtonNew South WalesAustralia2310
| | - Leeanne M Carey
- Florey Institute of Neuroscience and Mental Health, The University of MelbourneNeurorehabilitation and Recovery, Stroke DivisionMelbourneVictoriaAustralia3081
| | - Christine Imms
- Australian Catholic UniversityCentre for Disability & Development ResearchLevel 2, Daniel Mannix Building17 Young StreetMelbourneVictoriaAustralia3065
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Shierk A, Jiménez-Moreno AC, Roberts H, Ackerman-Laufer S, Backer G, Bard-Pondarre R, Cekmece C, Pyrzanowska W, Vilain C, Delgado MR. Development of a Pediatric Goal-Centered Upper Limb Spasticity Home Exercise Therapy Program for Use in a Phase-III Trial of Abobotulinumtoxina (Dysport ®). Phys Occup Ther Pediatr 2019; 39:124-135. [PMID: 30204515 DOI: 10.1080/01942638.2018.1486346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS To create a standardized home exercise therapy program that could be implemented by international sites to provide a consistent level of therapeutic intervention for pediatric patients participating in an ongoing Phase-III, randomized, controlled trial of repeat abobotulinumtoxinA injections for pediatric upper limb spasticity (NCT02106351). METHODS Physical therapists, occupational therapists, and medical doctors worked collaboratively to design an exercise therapy program to be implemented in the home setting. In this article, we describe the development process and the finalized program that is currently being used in the Phase-III trial. RESULTS The final program is presented as a "toolbox" for therapists, and includes a standardized step-wise process for choosing the most appropriate exercises and functional activities to achieve the agreed treatment goals of each abobotulinumtoxinA injection. The core toolbox includes: a clear protocol for clinicians, information sheets, signature of commitment forms, exercise score charts, and the library of exercises and functional activities that therapists choose from to aid the patient in achieving their treatment goals. CONCLUSIONS Implementation of this home therapy program provides a standardized background of good practice against which to test the efficacy of abobotulinumtoxinA. Preliminary data show that the program is readily accepted by patients and their families.
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Affiliation(s)
- Angela Shierk
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA
| | | | - Heather Roberts
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA
| | | | | | - Rachel Bard-Pondarre
- f Centre Médico-Chirurgical de Réadaptation des Massues - Croix-Rouge Française , Lyon , France
| | - Cigdem Cekmece
- g Department of Rehabilitation , Kocaeli University , Izmit , Turkey
| | - Weronika Pyrzanowska
- h Non-public Healthcare Unit Mazovian Neurorehabilitation and Psychiatry Center in Zagorze , Wiazowna , Poland
| | | | - Mauricio R Delgado
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA.,i Department of Neurology, University of Texas Southwestern Medical Center , Dallas , TX , USA
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Maltais DB, Ferland C, Perron M, Roy JS. Reliability of Inclinometer-Derived Passive Range of Motion Measures in Youth with Cerebral Palsy. Phys Occup Ther Pediatr 2019; 39:655-668. [PMID: 31144588 DOI: 10.1080/01942638.2019.1597822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Désirée B Maltais
- Department of Rehabilitation, Laval University , Quebec City , Quebec , Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration , Quebec City , Quebec , Canada
| | - Chantal Ferland
- Centre Integre Universitaire de Santé et de Services Sociaux de la Capitale-Nationale , Quebec City , Quebec , Canada
| | - Marc Perron
- Centre Integre Universitaire de Santé et de Services Sociaux de la Capitale-Nationale , Quebec City , Quebec , Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Laval University , Quebec City , Quebec , Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration , Quebec City , Quebec , Canada
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Novak I. Commentary on Development of a Pediatric Goal-Centered Upper Limb Spasticity Home Exercise Therapy Program. Phys Occup Ther Pediatr 2019; 39:136-138. [PMID: 30821172 DOI: 10.1080/01942638.2019.1573627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Iona Novak
- a Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, Faculty of Medicine and Health , The University of Sydney , Camperdown , NSW , Australia
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Klochkova OA, Kurenkov AL. Priorities and Goals of Botulinum Toxin A Treatment in Cerebral Palsy. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:118-124. [DOI: 10.17116/jnevro2019119021118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Juneja M, Jain R, Gautam A, Khanna R, Narang K. Effect of multilevel lower-limb botulinum injections & intensive physical therapy on children with cerebral palsy. Indian J Med Res 2018; 146:S8-S14. [PMID: 29578189 PMCID: PMC5890601 DOI: 10.4103/ijmr.ijmr_1223_15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives Botulinum toxin is considered as an effective treatment for spasticity in children with cerebral palsy (CP). However, there are only a few long-term studies, and the effects on motor function have been inconclusive. Moreover, due to its high cost and need for intensive post-injection therapy, utility in context of developing nations has not been established. This retrospective study was undertaken to assess the long term effects of botulinum toxin-A with physical therapy in children with CP. Methods This retrospective study was conducted at a tertiary care centre in India, where a limited supply of botulinum toxin was introduced in the year 2009. It was used in a selective group of patients with CP along with intensive physical therapies. All children who received lower-limb botulinum injections over a 42-month period were analyzed. For evaluation of treatment effect, the measurement at 1st pre-injection assessment and the last measurements, i.e. 12 wk after last injection received by that child were compared. Results Twenty nine patients (20 males, median age 51 months) received 69 sessions of botulinum toxin injections in the lower limbs over a 42-month period. Thirteen patients were diplegic, 10 were quadriplegic, five were triplegic and one was hemiplegic. There was a significant improvement in pre- and post-injection scores on Observational Gait Scale (right side 7.1±3.6 to 10.7±3.7, left side 6.7±3.5 to 9.9±3.4), Gross Motor Function Measure Scale (47.9±17.7 to 67.6±17.2), Modified Ashworth Scale, passive range of motion and Gross Motor Function Classification System. Most of the patients showed gain in motor milestones as well. Interpretation & conclusions Our results showed that judicious use of botulinum injections along with intensive physio/occupational therapies could yield good results in children with CP.
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Affiliation(s)
- Monica Juneja
- Child Development Center, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
| | - Rahul Jain
- Child Development Center, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
| | - Ankita Gautam
- Child Development Center, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
| | - Ritu Khanna
- Child Development Center, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
| | - Kamia Narang
- Child Development Center, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
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Synnot A, Chau M, Pitt V, O'Connor D, Gruen RL, Wasiak J, Clavisi O, Pattuwage L, Phillips K. Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev 2017; 11:CD008929. [PMID: 29165784 PMCID: PMC6486165 DOI: 10.1002/14651858.cd008929.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI. OBJECTIVES To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI. SEARCH METHODS In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data. MAIN RESULTS We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes. AUTHORS' CONCLUSIONS The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.
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Affiliation(s)
- Anneliese Synnot
- Monash UniversityCochrane Australia, School of Public Health and Preventive MedicineL4 551 St Kilda RdMelbourneVictoriaAustralia3004
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Marisa Chau
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Veronica Pitt
- Australian & New Zealand Intensive Care Research Centre (ANZIC‐RC), Monash UniversityLevel 6, The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Denise O'Connor
- Monash UniversitySchool of Public Health and Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Jason Wasiak
- University of MelbourneMelbourne School of Health SciencesGrattan Street, ParkvilleMelbourneVictoriaAustralia
| | - Ornella Clavisi
- MOVE muscle, bone & joint health263‐265 Kooyong Rd ElsternwickMelbourneVICAustralia3185
| | - Loyal Pattuwage
- Centre for Evidence and ImplementationEast MelbourneVICAustralia3175
| | - Kate Phillips
- Monash UniversitySchool of Public Health & Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
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[Modern non-cosmetic treatment with botulinum toxins]. Internist (Berl) 2017; 58:1332-1340. [PMID: 29030680 DOI: 10.1007/s00108-017-0323-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Botulinum toxin has been known in medical history for a long time. The first scientific investigations and thoughts on possible indications in the treatment of muscular disorders were published by the German physician and poet Justinus Kerner in 1822. The physiological effect of botulinum toxin was identified in the middle of the twentieth century and the first clinical use was reported in 1977. It was first used in ophthalmology for the correction of strabismus and some years later the therapy of blepharospasm and cervical dystonia was established. Further indications, all supported by randomized controlled studies, are spastic tone increase of the limbs after lesions of the central nervous system, idiopathic axillar hyperhidrosis, chronic migraine and neurogenic or idiopathic bladder hyperactivity. In addition to these indications, a large number of further possible options have been published in the literature. Beside its effect on transmission at the neuromuscular synapses, botulinum toxin has also been shown to affect the sensory transmission of nociceptive fibers.
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Mailleux L, Jaspers E, Ortibus E, Simon-Martinez C, Desloovere K, Molenaers G, Klingels K, Feys H. Clinical assessment and three-dimensional movement analysis: An integrated approach for upper limb evaluation in children with unilateral cerebral palsy. PLoS One 2017; 12:e0180196. [PMID: 28671953 PMCID: PMC5495347 DOI: 10.1371/journal.pone.0180196] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 06/12/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The clinical application of upper limb (UL) three-dimensional movement analysis (3DMA) in children with unilateral cerebral palsy (uCP) remains challenging, despite its benefits compared to conventional clinical scales. Moreover, knowledge on UL movement pathology and how this relates to clinical parameters remains scarce. Therefore, we investigated UL kinematics across different manual ability classification system (MACS) levels and explored the relation between clinical and kinematic parameters in children with uCP. PATIENTS AND METHODS Fifty children (MACS: I = 15, II = 26, III = 9) underwent an UL evaluation of sensorimotor impairments (grip force, muscle strength, muscle tone, two-point discrimination, stereognosis), bimanual performance (Assisting Hand Assessment, AHA), unimanual capacity (Melbourne Assessment 2, MA2) and UL-3DMA during hand-to-head, hand-to-mouth and reach-to-grasp tasks. Global parameters (Arm Profile Score (APS), duration, (timing of) maximum velocity, trajectory straightness) and joint specific parameters (angles at task endpoint, ROM and Arm Variable Scores (AVS)) were extracted. The APS and AVS refer respectively to the total amount of movement pathology and movement deviations of wrist, elbow, shoulder, scapula and trunk. RESULTS Longer movement durations and increased APS were found with higher MACS-levels (p<0.001). Increased APS was also associated with more severe sensorimotor impairments (r = -0.30-(-0.73)) and with lower AHA and MA2-scores (r = -0.50-(-0.86)). For the joint specific parameters, stronger movement deviations distally were significantly associated with increased muscle weakness (r = -0.32-(-0.74)) and muscle tone (r = 0.33-(-0.61)); proximal movement deviations correlated only with muscle weakness (r = -0.35-0.59). Regression analysis exposed grip force as the most important predictor for the variability in APS (p<0.002). CONCLUSION We found increased movement pathology with increasing MACS-levels and demonstrated the adverse impact of especially muscle weakness. The lower correlations suggest that 3DMA provides additional information regarding UL motor function, particularly for the proximal joints. Integrating both methods seems clinically meaningful to obtain a comprehensive representation of all aspects of a child's UL functioning.
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Affiliation(s)
- Lisa Mailleux
- KU Leuven–University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- * E-mail:
| | - Ellen Jaspers
- KU Leuven–University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Neural Control of Movement Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Els Ortibus
- KU Leuven–University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | | | - Kaat Desloovere
- KU Leuven–University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- University Hospitals Leuven, Clinical Motion Analysis Laboratory, Leuven, Belgium
| | - Guy Molenaers
- KU Leuven–University of Leuven, Department of Development and Regeneration, Leuven, Belgium
- University Hospitals Leuven, Department of Orthopaedic Medicine, Leuven, Belgium
| | - Katrijn Klingels
- KU Leuven–University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- UHasselt–Hasselt University, BIOMED, Rehabilitation Research Center (REVAL), Diepenbeek, Belgium
| | - Hilde Feys
- KU Leuven–University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
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Liao HH, Yen HR, Muo CH, Lee YC, Wu MY, Chou LW, Sun MF, Chang TT. Complementary traditional Chinese medicine use in Children with cerebral palsy: a nationwide retrospective cohort study in Taiwan. Altern Ther Health Med 2017; 17:155. [PMID: 28288600 PMCID: PMC5348761 DOI: 10.1186/s12906-017-1668-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/07/2017] [Indexed: 01/06/2023]
Abstract
Background Complementary traditional Chinese medicine (TCM) has been used to treat patients with cerebral palsy (CP). However, large-scale surveys examining its use in the treatment of CP and associated disorders are lacking. Methods We enrolled 11,218 patients ≤ 18 years of age with CP in the Taiwanese National Health Insurance Research Database from 1995 to 2011. Patients were categorized as TCM users (n = 6,997; 62.37%) and non-TCM users (n = 4,221; 37.63%) based on the inclusion of TCM in their treatment plan. Results Children with higher proportions of complementary TCM use were male, younger, and lived in urbanized areas. Most TCM users (n = 5332, 76.2%) visited TCM outpatient departments more than 20 times per year. In both groups, the three most common reasons for clinical visits were problems of the nervous system, respiratory system, and digestive system. Acupuncture was commonly used in problems of injury, musculoskeletal system and connective tissue, and nervous system. Chinese herbal medicine was used to improve the primary symptoms of CP in patients, as well as its associated disorders. The incidence rate ratios in allergic rhinitis, dyspepsia, menstrual disorders, and musculoskeletal system and connective tissue diseases among TCM users were significantly higher than non-TCM users. Although patients receiving complementary TCM therapies had higher medical expenditure for utilizing outpatient clinical consultations, their medical costs for visiting ER and hospitalization were significantly lower than that of non-TCM user within one year of the diagnosis of CP. Conclusion This study was a large-scale survey to characterize patterns of complementary TCM use among children with CP. The complementary use of TCM in children with CP was considerably high. Future clinical trials and basic researches can be developed based on the findings of this study.
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Preston N, Horton M, Levesley M, Mon-Williams M, O'Connor RJ. Development of a parent-reported questionnaire evaluating upper limb activity limitation in children with cerebral palsy. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2017; 23. [PMID: 28112465 PMCID: PMC5811897 DOI: 10.1002/pri.1684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 07/15/2016] [Accepted: 07/31/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Upper limb activity measures for children with cerebral palsy have a number of limitations, for example, lack of validity and poor responsiveness. To overcome these limitations, we developed the Children's Arm Rehabilitation Measure (ChARM), a parent-reported questionnaire validated for children with cerebral palsy aged 5-16 years. This paper describes both the development of the ChARM items and response categories and its psychometric testing and further refinement using the Rasch measurement model. METHODS To generate valid items for the ChARM, we collected goals of therapy specifically developed by therapists, children with cerebral palsy, and their parents for improving activity limitation of the upper limb. The activities, which were the focus of these goals, formed the basis for the items. Therapists typically break an activity into natural stages for the purpose of improving activity performance, and these natural orders of achievement formed each item's response options. Items underwent face validity testing with health care professionals, parents of children with cerebral palsy, academics, and lay persons. A Rasch analysis was performed on ChARM questionnaires completed by the parents of 170 children with cerebral palsy from 12 hospital paediatric services. The ChARM was amended, and the procedure repeated on 148 ChARMs (from children's mean age: 10 years and 1 month; range: 4 years and 8 months to 16 years and 11 months; 85 males; Manual Ability Classification System Levels I = 9, II = 26, III = 48, IV = 45, and V = 18). RESULTS The final 19-item unidimensional questionnaire displayed fit to the Rasch model (chi-square p = .18), excellent reliability (person separation index = 0.95, α = 0.95), and no floor or ceiling effects. Items showed no response bias for gender, distribution of impairment, age, or learning disability. DISCUSSION The ChARM is a psychometrically sound measure of upper limb activity validated for children with cerebral palsy aged 5-16 years. The ChARM is freely available for use to clinicians and nonprofit organisations.
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Affiliation(s)
- N Preston
- Academic Department of Rehabilitation Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - M Horton
- Academic Department of Rehabilitation Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - M Levesley
- School of Mechanical Engineering, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - M Mon-Williams
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - R J O'Connor
- National Demonstration Centre in Rehabilitation, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom of Great Britain and Northern Ireland.,Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
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What Does Cochrane Say about … the Treatment of Spasticity? Physiother Can 2017; 69:361. [PMID: 30369704 DOI: 10.3138/ptc.69.4.cochrane] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cloake T, Gardner A. The management of scoliosis in children with cerebral palsy: a review. JOURNAL OF SPINE SURGERY 2016; 2:299-309. [PMID: 28097247 DOI: 10.21037/jss.2016.09.05] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.
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Lorin K, Forsberg A. Treatment with botulinum toxin in children with cerebral palsy: a qualitative study of parents' experiences. Child Care Health Dev 2016; 42:494-503. [PMID: 27198886 DOI: 10.1111/cch.12350] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 03/30/2016] [Accepted: 04/24/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In children with cerebral palsy everyday movements such as walking, standing and using one's hands can be difficult to perform because of spasticity. Botulinum neurotoxin type A (BoNT-A) are often used to reduce spasticity. The aim of this study was to describe how parents of children with cerebral palsy experienced the child's treatment with BoNT-A, how the child was affected by the treatment and how spasticity affected the child. METHODS A qualitative study in which 15 parents of children (6-13 years old) with cerebral palsy were interviewed about their experiences of the BoNT-A treatment. The children had received several BoNT-A treatments. An interview guide was used with topics: the child's functions before and after the treatment, the outcomes of the treatment and how they valued the BoNT-A treatment. Content analysis was used to analyse the interviews. RESULTS The analyses resulted in two themes: 'When softness comes and goes' and 'Both want and do not want'. The reduction of spasticity - softness - was described to promote motor functions, and facilitate the next step in motor development. The children were described as being more active out of their own initiative and having a happier mood. Spasticity, described as stiffness, was described to make walking more strenuous as well as interfering with activities. The BoNT-A injection procedure was perceived as troublesome and painful for the child, and sometimes traumatic for both children and parents. CONCLUSIONS Treatment with BoNT-A was described as facilitating motor development and activity. The children's and the parents' negative experiences of the injection procedure should be addressed.
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Affiliation(s)
- K Lorin
- Child and Youth Habilitation Centre, Region Örebro County, Örebro, Sweden
| | - A Forsberg
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Imms C, Wallen M, Elliott C, Hoare B, Randall M, Greaves S, Adair B, Bradshaw E, Carter R, Orsini F, Shih STF, Reddihough D. Minimising impairment: Protocol for a multicentre randomised controlled trial of upper limb orthoses for children with cerebral palsy. BMC Pediatr 2016; 16:70. [PMID: 27230616 PMCID: PMC4882829 DOI: 10.1186/s12887-016-0608-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 05/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background Upper limb orthoses are frequently prescribed for children with cerebral palsy (CP) who have muscle overactivity predominantly due to spasticity, with little evidence of long-term effectiveness. Clinical consensus is that orthoses help to preserve range of movement: nevertheless, they can be complex to construct, expensive, uncomfortable and require commitment from parents and children to wear. This protocol paper describes a randomised controlled trial to evaluate whether long-term use of rigid wrist/hand orthoses (WHO) in children with CP, combined with usual multidisciplinary care, can prevent or reduce musculoskeletal impairments, including muscle stiffness/tone and loss of movement range, compared to usual multidisciplinary care alone. Methods/design This pragmatic, multicentre, assessor-blinded randomised controlled trial with economic analysis will recruit 194 children with CP, aged 5–15 years, who present with flexor muscle stiffness of the wrist and/or fingers/thumb (Modified Ashworth Scale score ≥1). Children, recruited from treatment centres in Victoria, New South Wales and Western Australia, will be randomised to groups (1:1 allocation) using concealed procedures. All children will receive care typically provided by their treating organisation. The treatment group will receive a custom-made serially adjustable rigid WHO, prescribed for 6 h nightly (or daily) to wear for 3 years. An application developed for mobile devices will monitor WHO wearing time and adverse events. The control group will not receive a WHO, and will cease wearing one if previously prescribed. Outcomes will be measured 6 monthly over a period of 3 years. The primary outcome is passive range of wrist extension, measured with fingers extended using a goniometer at 3 years. Secondary outcomes include muscle stiffness, spasticity, pain, grip strength and hand deformity. Activity, participation, quality of life, cost and cost-effectiveness will also be assessed. Discussion This study will provide evidence to inform clinicians, services, funding agencies and parents/carers of children with CP whether the provision of a rigid WHO to reduce upper limb impairment, in combination with usual multidisciplinary care, is worth the effort and costs. Trial registration ANZ Clinical Trials Registry: U1111-1164-0572.
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Affiliation(s)
- Christine Imms
- Centre for Disability and Development Research, Faculty of Health Sciences, Australian Catholic University, 17 Young Street, Fitzroy, VIC, 3065, Australia.
| | - Margaret Wallen
- Cerebral Palsy Alliance, PO Box 6427, Frenchs Forest, NSW, 2086, Australia
| | - Catherine Elliott
- School of Occupational Therapy and Social Work, Curtin University, Bentley, Australia
| | - Brian Hoare
- Monash Children's Hospital, Clayton, Australia
| | - Melinda Randall
- Centre for Disability and Development Research, Faculty of Health Sciences, Australian Catholic University, 17 Young Street, Fitzroy, VIC, 3065, Australia
| | - Susan Greaves
- Royal Children's Hospital, Flemington Rd, Parkville, 3052, Australia
| | - Brooke Adair
- Centre for Disability and Development Research, Faculty of Health Sciences, Australian Catholic University, 17 Young Street, Fitzroy, VIC, 3065, Australia
| | - Elizabeth Bradshaw
- Centre for Disability and Development Research, Faculty of Health Sciences, Australian Catholic University, 17 Young Street, Fitzroy, VIC, 3065, Australia
| | - Rob Carter
- Deakin University, Building BC, Room BC3.113, 221 Burwood Highway, Burwood, Australia
| | | | - Sophy T F Shih
- Deakin University, Building BC, Room BC3.113, 221 Burwood Highway, Burwood, Australia
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Shierk A, Lake A, Haas T. Review of Therapeutic Interventions for the Upper Limb Classified by Manual Ability in Children with Cerebral Palsy. Semin Plast Surg 2016; 30:14-23. [PMID: 26869859 DOI: 10.1055/s-0035-1571256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The aim of this literature review was to assemble an inventory of intervention strategies utilized for children diagnosed with cerebral palsy (CP) based on the Manual Ability Classification System (MACS). The purpose of the inventory is to guide physicians and therapists in intervention selection aimed at improving upper limb function in children with CP. The following databases were searched: CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Database of Systematic Reviews, ERIC (Educational Research Information Center), Google Scholar, OTSeeker (Occupational Therapy Systematic Evaluation of Evidence), OVID (Ovid Technologies, Inc.), and PubMed. Inclusion criteria were whether the study (1) identified MACS levels of participants, and (2) addressed the effectiveness of intervention on upper limb function. Overall, 74 articles met the inclusion criteria. The summarized data identified 10 categories of intervention. The majority of participants across studies were MACS level II. The most frequently cited interventions were constraint-induced movement therapy (CIMT), bimanual training, and virtual reality and computer-based training. Multiple interventions demonstrated effectiveness for upper limb improvement at each MACS level. However, there is a need for additional research for interventions appropriate for MACS levels IV and V. To fully develop an intervention inventory based on manual ability, future studies need to report MACS levels of participants, particularly for splinting and therapy interventions used in combination with surgery.
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Affiliation(s)
- Angela Shierk
- Occupational Therapy, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Amy Lake
- Occupational Therapy, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Tara Haas
- Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas
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Lin YC, Huang CY, Lin IL, Shieh JY, Chung YT, Chen KL. Evaluating Functional Outcomes of Botulinum Toxin Type A Injection Combined with Occupational Therapy in the Upper Limbs of Children with Cerebral Palsy: A 9-Month Follow-Up from the Perspectives of Both Child and Caregiver. PLoS One 2015; 10:e0142769. [PMID: 26599003 PMCID: PMC4657995 DOI: 10.1371/journal.pone.0142769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To assess the effectiveness of combining botulinum toxin type A (BoNT-A) with functional occupational therapy (OT) at 9-month follow-up in children with cerebral palsy (CP) with bilateral upper limb impairments from the perspectives of both child and caregiver. Methods Twelve children with CP and their caregivers were assessed across 5 time points over 9 months based on the ICF after BoNT-A injection and functional OT in this open-label study. Results Significant differences were found across the 5 time points (p < .05) for both grasp and visual-motor integration with small effects (effect sizes = 0.12–0.24) and the self-care capability and performance of social function (p < .05). However, based on the effect sizes (0.02–0.14), no significant effects were found at the 4 post-test time points. Small effects were found on the psychological domain (effect sizes = 0.25–0.37) and environmental domains (effect size = 0.27) at follow-ups. Conclusion Combining a BoNT-A injection with OT not only reduced the muscle tone and increased ROM but also improved the upper limb function and self-care capability in children with CP. More importantly, these effects persisted for up to 9 months. Functional OT extends the effectiveness of a BoNT-A injection.
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Affiliation(s)
- Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Yu Huang
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - I-Ling Lin
- Department of Medical Laboratory Sciences and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jeng-Yi Shieh
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Yu-Ting Chung
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Lin Chen
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- School of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail:
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Abstract
Tone management is one of the primary roles of a pediatric physiatrist. Hypertonicity frequently inhibits normal movement patterns in children with central nervous system lesions but at times can reinforce muscle group firing and be useful for a child's function. Treatment approaches should be individualized based on functional goals, degree of impairment, interference with care, and type and location of hypertonicity. Treatment plans should be created in collaboration with all individuals caring for the child. There are many causes of hypertonicity as well as many nonsurgical and surgical treatments. Historical and current evidence-based treatments are reviewed.
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Affiliation(s)
- Sathya Vadivelu
- Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, Rady Children's Hospital San Diego, University of California San Diego, 3020 Children's Way MC5096, San Diego, CA 92123, USA
| | - Anne Stratton
- Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO, USA
| | - Wendy Pierce
- Department of Physical Medicine and Rehabilitation, University of Colorado, 4125 Briargate Parkway, Box 520, Colorado Springs, CO 80920, USA.
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Speth L, Janssen-Potten Y, Rameckers E, Defesche A, Winkens B, Becher J, Smeets R, Vles H. Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity activities in unilateral Cerebral Palsy: a clinical trial. BMC Neurol 2015; 15:143. [PMID: 26286662 PMCID: PMC4544795 DOI: 10.1186/s12883-015-0404-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 08/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy (uCP) combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately. Bimanual activities were measured with the Assisting Hand Assessment (AHA), the ABILHand-Kids questionnaire (AK), the Observational Skills Assessment Score (OSAS). Goal achievement was measured with Goal Attainment Scaling (GAS), using blind video assessment, and the Canadian Occupational Performance Measure (COPM). METHODS Thirty-five children, mean age 7.14 years (SD 2.63), 11 Manual Ability Classification Score (MACS) I, 15 MACS II and 9 MACS III, participated. The trial started with four study groups: BoNT-A-only (n = 5), BITT-only (n = 11), BoNT-A + BITT (n = 13), and control (n = 6). Twenty-two children were randomised, 13 children received their parents' preferred treatment: BoNT-A + BITT or BITT-only. Three comparisons were analysed: BITT (BoNT-A + BITT and BITT-only; n = 24) versus no BITT (BoNT-A-only and control; n = 11), BoNT-A (BoNT-A-only and BoNT-A + BITT; n = 18) versus no BoNT-A (BITT-only and control; n = 17), and the additional effect of BoNT-A (BoNT-A + BITT versus BITT-only). Follow-up time: 24 weeks. RESULTS No significant differences between the groups were found on the AHA. The amount of use of both hands on the OSAS was significantly better in the BoNT-A group in the beading and sandwich-making task. The BoNT-A group also showed significant improvement in the quality scores of the OSAS: the wrist position during grasping and holding, especially in the younger children. The BITT group improved significantly on the AK and significantly more on the performance and satisfaction scores of the COPM at 12 and 24 weeks regarding several goals. BoNT-A showed a significant negative effect at 12 and 24 weeks in the most important goal. BITT, more than BoNT-A + BITT, showed positive effects on the GAS score at 12 (significant), 18 and 24 weeks. CONCLUSIONS BoNT-A has a positive effect on quality of movement and amount of use of the affected UE during the 3 months' working time. BoNT-A has no additional effect on bimanual performance and goal achievement. BITT has a positive effect on goal achievement and bimanual performance, even up to 6 weeks after therapy had stopped. TRIAL REGISTRATION Current Controlled Trials ISRCTN69541857.
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Affiliation(s)
- Lucianne Speth
- Adelante, Paediatric Rehabilitation, Onderstestraat 29, 6301 , KA, Valkenburg, The Netherlands. .,Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 , CC, Hoensbroek, The Netherlands.
| | - Yvonne Janssen-Potten
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 , CC, Hoensbroek, The Netherlands. .,Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRI, PO Box 616, 6200 , MD, Maastricht, The Netherlands.
| | - Eugene Rameckers
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 , CC, Hoensbroek, The Netherlands. .,Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRI, PO Box 616, 6200 , MD, Maastricht, The Netherlands.
| | - Anke Defesche
- Adelante, Paediatric Rehabilitation, Onderstestraat 29, 6301 , KA, Valkenburg, The Netherlands.
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Research School CAPHRI, Maastricht, The Netherlands.
| | - Jules Becher
- Department of Rehabilitation Medicine, Free University Medical Centre, De Boelelaan 1118, 1081 , HZ, Amsterdam, The Netherlands.
| | - Rob Smeets
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 , CC, Hoensbroek, The Netherlands. .,Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRI, PO Box 616, 6200 , MD, Maastricht, The Netherlands. .,Department of Rehabilitation Medicine, Maastricht University Medical Centre, PO Box 5200, 6202 , AZ, Maastricht, The Netherlands.
| | - Hans Vles
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Department of Neurology, Maastricht University, Research School GROW, Maastricht, The Netherlands.
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Strobl W, Theologis T, Brunner R, Kocer S, Viehweger E, Pascual-Pascual I, Placzek R. Best clinical practice in botulinum toxin treatment for children with cerebral palsy. Toxins (Basel) 2015; 7:1629-48. [PMID: 25969944 PMCID: PMC4448165 DOI: 10.3390/toxins7051629] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/29/2015] [Accepted: 05/05/2015] [Indexed: 11/16/2022] Open
Abstract
Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.
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Affiliation(s)
- Walter Strobl
- Department of Paediatric- and Neuro-Orthopaedics, Orthopaedic Hospital Rummelsberg, 90592 Schwarzenbruck, Germany and MOTIO, 1080 Vienna, Austria.
| | - Tim Theologis
- Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road Headington, Oxford OX3 7LD, Oxfordshire, UK.
| | - Reinald Brunner
- Department of Paediatric- and Neuro-Orthopaedics, University Children's Hospital Basel (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland.
| | - Serdar Kocer
- Centre de Réadaptation de COUBERT (Ugecam) 77170, France and ROMATEM, Etiler Istanbul 34337, Turkey.
| | - Elke Viehweger
- Pediatric Orthopaedics and Institue of Motion Sciences Department, Aix-Marseille Université, Boulevard Jean Moulin, Marseille 13885, France.
| | - Ignacio Pascual-Pascual
- Department of Paediatrics, Hospital Infantil La Paz, Universidad Autonóma de Madrid, Madrid, Spain.
| | - Richard Placzek
- Orthopedic Department, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany.
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Beecham E, Candy B, Howard R, McCulloch R, Laddie J, Rees H, Vickerstaff V, Bluebond‐Langner M, Jones L. Pharmacological interventions for pain in children and adolescents with life-limiting conditions. Cochrane Database Syst Rev 2015; 2015:CD010750. [PMID: 25768935 PMCID: PMC6481584 DOI: 10.1002/14651858.cd010750.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain is one of the most common symptoms in children and young people (CYP) with life-limiting conditions (LLCs) which include a wide range of diagnoses including cancer. The current literature indicates that pain is not well managed, however the evidence base to guide clinicians is limited. There is a clear need for evidence from a systematic review to inform prescribing. OBJECTIVES To evaluate the evidence on the effectiveness of different pharmacological interventions used for pain in CYP with LLCs. SEARCH METHODS The following electronic databases were searched up to December 2014: CENTRAL (in the Cochrane Library), MEDLINE, EMBASE, PsycINFO and CINAHL. In addition, we searched conference proceedings and reference lists of included studies. For completeness, we also contacted experts in the field. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-randomised studies and other studies that included a clearly defined comparator group were included. The studies investigated pharmacological treatments for pain associated with LLCs in CYP. The treatment included those specifically developed to treat pain and those that acted as an adjuvant, where the treatment was not primarily developed to treat pain but has pain relieving properties. The LLC was identified by its inclusion in the Richard Hain Directory of LLCs. DATA COLLECTION AND ANALYSIS Citations were screened by five review authors. Data were extracted by one review author and checked by a second. Two review authors assessed the risk of bias of included studies. A sufficient number of studies using homogeneous outcomes was not identified so a meta-analysis was not possible. MAIN RESULTS We identified 24,704 citations from our database search. Nine trials with 379 participants fulfilled our inclusion criteria. Participants had cerebral palsy (CP) in five of the studies and osteogenesis imperfecta (OI) in the other four. Participants across the trials ranged in age from 2 to 19 years. All studies, apart from one cross-over trial, were parallel designed RCTs. Three of the trials on CP evaluated intrathecal baclofen (ITB) and two botulinum toxin A (BoNT-A). All of the OI trials evaluated the use of bisphosphonates (two alendronate and one pamidronate). No trials were identified that evaluated a commonly used analgesic in this patient group. Pain was a secondary outcome in five of the eight identified studies. Overall the quality of the trials was mixed. Only one study involved over 100 participants.For the two ITB studies for pain in CP, in the same study population but assessed at different time points in their disease, both found an effect on pain favouring the intervention compared to the control group (standard care or placebo) (mean difference (MD) 4.20, 95% confidence interval (CI) 2.15 to 6.25; MD 26.60, 95% CI 2.61 to 50.59, respectively). In these studies most of the adverse events related to the procedure or device for administration rather than the drug, such as swelling at the pump site. In one trial there were also eight serious adverse effects; these included difficulty swallowing and an epileptic seizure. The trial did not state if these occurred in the intervention group. At follow-up in both BoNT-A trials there was no evidence of a difference in pain between the trial arms among CP participants. The adverse events in the BoNT-A trials mostly involved those who received the intervention drug and involved seizures. Gastrointestinal problems were the most frequent adverse event in those who received alendronate. The trial investigating pamidronate found no evidence of a difference in pain compared to the control group. No adverse events were reported in this trial. AUTHORS' CONCLUSIONS Published, controlled evidence on the pharmacological interventions for pain in CYP with LLCs is limited. The evidence that is currently available evaluated pain largely as a secondary outcome and the drugs used were all adjuvants and not always commonly used in general paediatric palliative care for pain. Based on current data this systematic review is unable to determine the effects of pharmacological interventions for pain for CYP with LLCs. Future trials with larger populations should examine the effects of the drugs commonly used as analgesics; with the rising prevalence of many LLCs this becomes more necessary.
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Affiliation(s)
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
| | - Richard Howard
- Great Ormond Street HospitalAnaesthesia and Pain ManagementGreat Ormond StreetLondonUKWC1N 3JH
| | - Renée McCulloch
- Great Ormond Street HospitalLouis Dundas Centre for Children's Palliative Care, Palliative Care TeamLondonUK
| | - Jo Laddie
- Evelina London Children's HospitalDepartment of Paediatric Palliative MedicineLondonUK
| | - Henrietta Rees
- UCL Institute of Child HealthLouis Dundas Centre for Children's Palliative CareLondonUK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
| | | | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of PsychiatryCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Loi EC, Buysse CA, Price KS, Jaramillo TM, Pico EL, Hansen AB, Feldman HM. Myofascial Structural Integration Therapy on Gross Motor Function and Gait of Young Children with Spastic Cerebral Palsy: A Randomized Controlled Trial. Front Pediatr 2015; 3:74. [PMID: 26442234 PMCID: PMC4564770 DOI: 10.3389/fped.2015.00074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/19/2015] [Indexed: 11/29/2022] Open
Abstract
Though the cause of motor abnormalities in cerebral palsy is injury to the brain, structural changes in muscle and fascia may add to stiffness and reduced function. This study examined whether myofascial structural integration therapy, a complementary treatment that manipulates muscle and fascia, would improve gross motor function and gait in children <4 years with cerebral palsy. Participants (N = 29) were enrolled in a randomized controlled trial (NCT01815814, https://goo.gl/TGxvwd) or Open Label Extension. The main outcome was the Gross Motor Function Measure-66 assessed at 3-month intervals. Gait (n = 8) was assessed using the GAITRite(®) electronic walkway. Parents completed a survey at study conclusion. Comparing Treatment (n = 15) and Waitlist-Control groups (n = 9), we found a significant main effect of time but no effect of group or time × group interaction. The pooled sample (n = 27) showed a main effect of time, but no significantly greater change after treatment than between other assessments. Foot length on the affected side increased significantly after treatment, likely indicating improvement in the children's ability to approach a heel strike. Parent surveys indicated satisfaction and improvements in the children's quality of movement. MSI did not increase the rate of motor skill development, but was associated with improvement in gait quality.
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Affiliation(s)
- Elizabeth C Loi
- Department of Pediatrics, Stanford University School of Medicine , Palo Alto, CA , USA
| | - Christina A Buysse
- Department of Pediatrics, Stanford University School of Medicine , Palo Alto, CA , USA
| | - Karen S Price
- Advanced Rolfing, Private Practice , Palo Alto, CA , USA
| | - Theresa M Jaramillo
- Physical Therapy and Rehabilitation Science, University of California San Francisco , San Francisco, CA , USA
| | - Elaine L Pico
- Pediatric Rehabilitation, Santa Clara Valley Medical Center , San Jose, CA , USA
| | - Alexis B Hansen
- Department of Family Medicine, Providence Milwaukie Hospital , Milwaukie, OR , USA
| | - Heidi M Feldman
- Department of Pediatrics, Stanford University School of Medicine , Palo Alto, CA , USA
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Kurenkov AL, Klochkova OA, Karimova KM, Bursagova BI, Namazova-baranova LS, Kuzenkova LM, Mamedyarov AM, Artemenko AR, Petrova SA. Selection of a dose of the botulinum toxin A in spastic forms of cerebral palsy. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:35-41. [DOI: 10.17116/jnevro20151155235-41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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48
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Usos prácticos de la toxina botulínica en niños y adolescentes en medicina física y rehabilitación. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lee JS, Lee KB, Lee YR, Choi YN, Park CW, Park SD, Jung DH, Lee CS. Botulinum Toxin Treatment on Upper Limb Function in School Age Children With Bilateral Spastic Cerebral Palsy: One Year Follow-up. Ann Rehabil Med 2013; 37:328-35. [PMID: 23869330 PMCID: PMC3713289 DOI: 10.5535/arm.2013.37.3.328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 10/11/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To prospectively investigate the long-term effects of botulinum toxin treatment on the upper limb function and performance of school age children with spastic bilateral cerebral palsy, who have limitations in performing activities of daily living and school activities, due to spasticity of the upper extremities. METHODS Botulinum type A toxin (BoNT-A) was injected into 24 spastic upper limbs of 15 children. We used a Modified Ashworth Scale and a Modified Tardieu Scale for the evaluation of upper limb spasticity, and Quality of Upper Extremity Skills Test (QUEST), Canadian Occupational Performance Measure (COPM), and Test of Visual-Motor Skills-Revised (TVMS-R) for the evaluation of upper limb function and performance. RESULTS Upper limb spasticity continuously decreased until the end of the one-year follow-up. Upper limb function on QUEST and COPM showed the best performance at 3 months and deteriorated slightly, but still showed a significantly better performance at 9 and 12 months than at pre-injection. In more functional nine subjects who could perform TVMS-R, the performance enhancement effects remained constant after 12 months, suggesting that the reduced spasticity led to the learning effect acquired by the repeated use of the affected upper limb. CONCLUSION For school age children with bilateral spastic cerebral palsy whose upper limb functions are important, BoNT-A injections seem to be of help in the performance of school activities and activities of daily living.
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Affiliation(s)
- Jee Sun Lee
- Department of Rehabilitation Medicine, Seoul Rehabilitation Hospital, Seoul, Korea
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50
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Abrams SB, Hallett M. Clinical utility of different botulinum neurotoxin preparations. Toxicon 2013; 67:81-6. [DOI: 10.1016/j.toxicon.2012.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 11/27/2012] [Accepted: 11/29/2012] [Indexed: 12/26/2022]
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