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Mohamed AA, Faragalla S, Khan A, Flynn G, Rainone G, Johansen PM, Lucke-Wold B. Neurosurgical and pharmacological management of dystonia. World J Psychiatry 2024; 14:624-634. [PMID: 38808085 PMCID: PMC11129150 DOI: 10.5498/wjp.v14.i5.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/20/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
Dystonia characterizes a group of neurological movement disorders characterized by abnormal muscle movements, often with repetitive or sustained contraction resulting in abnormal posturing. Different types of dystonia present based on the affected body regions and play a prominent role in determining the potential efficacy of a given intervention. For most patients afflicted with these disorders, an exact cause is rarely identified, so treatment mainly focuses on symptomatic alleviation. Pharmacological agents, such as oral anticholinergic administration and botulinum toxin injection, play a major role in the initial treatment of patients. In more severe and/or refractory cases, focal areas for neurosurgical intervention are identified and targeted to improve quality of life. Deep brain stimulation (DBS) targets these anatomical locations to minimize dystonia symptoms. Surgical ablation procedures and peripheral denervation surgeries also offer potential treatment to patients who do not respond to DBS. These management options grant providers and patients the ability to weigh the benefits and risks for each individual patient profile. This review article explores these pharmacological and neurosurgical management modalities for dystonia, providing a comprehensive assessment of each of their benefits and shortcomings.
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Affiliation(s)
- Ali Ahmed Mohamed
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Steven Faragalla
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Asad Khan
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Garrett Flynn
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Gersham Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Phillip Mitchell Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
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Lee S, Jung YJ. Newly diagnosed Parkinson's disease in a middle-aged cerebral palsy patient with schizencephaly. Acta Neurol Belg 2024; 124:733-735. [PMID: 37925661 DOI: 10.1007/s13760-023-02417-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Sangjee Lee
- Department of Physical Medicine and Rehabilitation, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yu Jin Jung
- Department of Neurology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 64 Deheung-ro, Jung-gu, Daejeon, 34943, Republic of Korea.
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Hayashi K, Asano R, Sato M, Nakaya Y, Suzuki A, Takaku N, Hayashi K, Kobayashi Y. Efficacy of Trihexyphenidyl on Apraxia of Eyelid Opening in Parkinsonism: A Case Report. Cureus 2024; 16:e56232. [PMID: 38618350 PMCID: PMC11016287 DOI: 10.7759/cureus.56232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 04/16/2024] Open
Abstract
Apraxia of eyelid opening (AEO) is occasionally seen in Parkinson's disease (PD) or related diseases. However, many clinicians have trouble with the management of AEO by Parkinsonism. In this report, we describe a case of AEO in Parkinsonism improved by trihexyphenidyl (THP). The patient was a 64-year-old woman, who was previously healthy but developed bradykinesia. She was clinically diagnosed as PD due to an L-dopa challenge test, but no other detailed tests were performed. She started antiparkinsonian medications and her symptoms were improved at an early phase. However, her motor symptoms were gradually exacerbated over time, and antiparkinsonian medications were dosed up. At 69 years old, blepharospasm and AEO developed. Although other antiparkinsonian medications did not improve her AEO, THP cured AEO dramatically at 73 years old. In this report, we discuss a mechanism of AEO by Parkinsonism and the pathway of THP for the improvement of AEO.
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Affiliation(s)
- Koji Hayashi
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Rei Asano
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Mamiko Sato
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Yuka Nakaya
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Asuka Suzuki
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Naoko Takaku
- Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | - Kouji Hayashi
- Graduate School of Health Science, Fukui Health Science University, Fukui, JPN
| | - Yasutaka Kobayashi
- Graduate School of Health Science, Fukui Health Science University, Fukui, JPN
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Kumar S, Shankar Kaushik J, Verma S, Dabla S. Gabapentin as Add-on Therapy to Trihexyphenidyl in Children with Dyskinetic Cerebral Palsy: A Randomized, Controlled Trial. Indian J Pediatr 2023; 90:873-879. [PMID: 35867274 DOI: 10.1007/s12098-022-04265-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/29/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare the efficacy of gabapentin as add-on therapy to trihexyphenidyl in the treatment of children with dyskinetic cerebral palsy (CP). METHODS An open-labelled, randomized, controlled trial was conducted among children aged 3-9 y with dyskinetic CP [Gross Motor Functional Classification System (GMFCS) 4-5]. Participants were assigned into two groups: gabapentin with trihexyphenidyl (n = 30) and trihexyphenidyl alone (n = 30). Dyskinesia Impairment Scale (DIS), Dystonia Severity Assessment Plan (DSAP), and International Classification of Functioning, Disability, and Health-Children and Youth Version (ICF-CY) were measured at baseline, 4 and 12 wk. RESULTS There was significant reduction in baseline dystonia in both the groups (DIS: p < 0.001; DSAP: p = 0.007; ICF-CY: p < 0.001) but when data were compared between the groups, there was no significant difference in the severity of dystonia at 4 wk and at 12 wk (DIS: p = 0.09; DSAP: p = 0.49; ICF-CY: p = 0.25). Constipation was the commonest side effect observed in both the groups [3 (11.5%) vs. 4 (14.3%)]. CONCLUSION Trihexyphenidyl alone is as effective as combination of gabapentin with trihexyphenidyl in decreasing the severity of dystonia at 12 wk. Hence, there is no added benefit of gabapentin as add-on therapy for dystonia among children with dyskinetic CP. TRIAL REGISTRATION CTRI/2019/04/018603.
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Affiliation(s)
- Sonu Kumar
- Department of Pediatrics, SGT University, Gurugram, Haryana, India
| | - Jaya Shankar Kaushik
- Department of Pediatrics, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, 124001, India.
| | - Savita Verma
- Department of Pharmacology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Surekha Dabla
- Department of Neurology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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M A, Chakrabarty B. Brewing Evidence for Pharmacotherapy in Dyskinetic Cerebral Palsy: A Step in the Right Direction. Indian J Pediatr 2023; 90:853-854. [PMID: 37277685 DOI: 10.1007/s12098-023-04670-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/07/2023]
Affiliation(s)
- Aakash M
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Biswaroop Chakrabarty
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Stefanac S, Oppenauer C, Zauner M, Durechova M, Dioso D, Aletaha D, Hobusch G, Windhager R, Stamm T. From individualised treatment goals to personalised rehabilitation in osteoarthritis: a longitudinal prospective mapping study using the WHO international classification for functioning, disability and health. Ann Med 2022; 54:2816-2827. [PMID: 36259346 PMCID: PMC9586611 DOI: 10.1080/07853890.2022.2131326] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND/OBJECTIVE(S)/INTRODUCTION In clinical practice, treatment goals are often set up without exploring what patients really want. We, therefore, collected individualised treatment goals of patients with osteoarthritis (OA), categorised and mapped them to the World Health Organisation International Classification for Functioning, Disability and Health (ICF). PATIENTS/MATERIALS AND METHODS A longitudinal prospective cohort study was conducted (2019-2021). We used descriptive statistics and Chi2/Fisher's Exact Tests, where appropriate, as well as Kruskal-Wallis-Tests for the mean score ranks of the patients' goals. RESULTS In total, 305 goals reported by 132 participants were analysed (267 women vs. 38 men). The top 3 ICF categories were sensation of pain (ICF:b280), mobility of joint (ICF:b710) and muscle power functions (ICF:b730). Overall, 51% of all individually reported functional goals were achieved after 3 months. Men were more likely to achieve their goals than women (p = 0.009). The majority of the "very important" goals (51%) and "very difficult" goals (57%) was not improved. Goals' mean score ranks significantly differed between baseline and follow-up. CONCLUSION(S) As the human lifespan as well as the number of people affected by OA worldwide increase, there is a growing need to identify and evaluate rehabilitation outcomes that are relevant to people with OA.Key MessagesTreat-to-target agreements between patients and health care providers present a step towards more personalised precision medicine, which will eventually lead to better reported functional and health outcomes.In patients with osteoarthritis, the Goal Attainment Scale instrument can be used to measure health outcomes at different time points and its content may be linked to ICF providing a unified language and conceptual scientific basis.
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Affiliation(s)
- Sinisa Stefanac
- Institute for Outcomes Research, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Claudia Oppenauer
- Karl Landsteiner Private University for Health Sciences, Krems, Lower Austria
| | - Michael Zauner
- Clinical Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Martina Durechova
- Clinical Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daffodil Dioso
- Clinical Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Clinical Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Gerhard Hobusch
- Department of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Institute for Outcomes Research, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
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Rajkumar L, Ventatakrishnan A, Sairam S, Khosla M, Khanna R, Das B, Mishra D, Juneja M. Trihexyphenidyl in young children with dystonic cerebral palsy: A single arm study. J Pediatr Rehabil Med 2022; 16:115-124. [PMID: 36373299 DOI: 10.3233/prm-210087] [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: 11/09/2022] Open
Abstract
PURPOSE The incidence of dystonic cerebral palsy causing significant morbidity is on the rise. There is a paucity of evidence for the management of dystonia in children. METHODS Forty-one children aged 6 months-5 years with predominantly dystonic cerebral palsy were started on a predetermined protocol of trihexyphenidyl (0.25-0.52 mg/kg) and followed up at 3, 6 and 12 weeks. Dystonia severity, motor function and developmental age at baseline and 12 weeks were compared using the Global Dystonia Scale (GDS), the Gross Motor Function Measure (GMFM), and Fine Motor/Perceptual Subscale of the Early Developmental Profile-2. Thirty-four children completed the entire 12 weeks of intervention. RESULTS The mean age of participants was 25±11 months. A significant decrease in median total dystonia scores on the GDS was observed post-intervention (74.5 to 59, p < 0.0001), and 64% of participants gained motor milestones. GMFM scores increased significantly from a median of 19.8% pre-intervention to 26.5% post-intervention (p < 0.0001). There was improvement in the fine motor domain as compared to the baseline (p < 0.0001). The number of children classified at Gross Motor Function Classification System levels 1 and 2 increased to 47.05% from 5.88% in the pre-intervention group. CONCLUSION Trihexyphenidyl significantly improved dystonia, motor function and development in children with dystonic cerebral palsy in this study. Additional studies are needed to clarify its role in larger numbers of children with this condition.
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Affiliation(s)
- Lavanya Rajkumar
- Department of Paediatrics, Maulana Azad Medical College & Lok Nayak hospital, New Delhi, India
| | | | - Smitha Sairam
- Department of Paediatrics, Maulana Azad Medical College & Lok Nayak hospital, New Delhi, India
| | - Megha Khosla
- Child Development Centre, Lok Nayak Hospital, New Delhi, India
| | - Ritu Khanna
- Child Development Centre, Lok Nayak Hospital, New Delhi, India
| | - Biswajit Das
- Child Development Centre, Lok Nayak Hospital, New Delhi, India
| | | | - Monica Juneja
- Department of Paediatrics, Maulana Azad Medical College & Lok Nayak hospital, New Delhi, India
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Abstract
The dystonias are a large and heterogenous group of disorders characterized by excessive muscle contractions leading to abnormal postures and/or repetitive movements. Their clinical manifestations vary widely, and there are many potential causes. Despite the heterogeneity, helpful treatments are available for the vast majority of patients. Symptom-based therapies include oral medications, botulinum toxins, and surgical interventions. For some subtypes of dystonia, specific mechanism-based treatments are available. Advances in understanding the biological basis for many types of dystonia have led to numerous recent clinical trials, so additional treatments are likely to become available in the very near future.
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Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Namara MM, Paton MC, Popat H, Shore B, Khamis A, Stanton E, Finemore OP, Tricks A, Te Velde A, Dark L, Morton N, Badawi N. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 2020; 20:3. [PMID: 32086598 PMCID: PMC7035308 DOI: 10.1007/s11910-020-1022-z] [Citation(s) in RCA: 446] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.
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Affiliation(s)
- Iona Novak
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia.
| | - Catherine Morgan
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Michael Fahey
- Department of Paediatric Neurology, Monash Health, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Megan Finch-Edmondson
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Claire Galea
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ashleigh Hines
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Katherine Langdon
- Department of Paediatric Rehabilitation, Kids Rehab WA, Perth Children's Hospital, Perth, Australia
| | - Maria Mc Namara
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Madison Cb Paton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Himanshu Popat
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Benjamin Shore
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda Khamis
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Emma Stanton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Olivia P Finemore
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Alice Tricks
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Anna Te Velde
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Leigha Dark
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Natalie Morton
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- School of Allied Health, Australian Catholic University, North Sydney, New South Wales, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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Harvey AR, Baker LB, Reddihough DS, Scheinberg A, Williams K. Trihexyphenidyl for dystonia in cerebral palsy. Cochrane Database Syst Rev 2018; 5:CD012430. [PMID: 29763510 PMCID: PMC6494536 DOI: 10.1002/14651858.cd012430.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cerebral palsy occurs in up to 2.1 of every 1000 live births and encompasses a range of motor problems and movement disorders. One commonly occurring movement disorder amongst those with cerebral palsy is dystonia: sustained or intermittent involuntary muscle spasms and contractions that cause twisting, repetitive movements and abnormal postures. The involuntary contractions are often very painful and distressing and cause significant limitations to activity and participation.Oral medications are often the first line of medical treatment for dystonia. Trihexyphenidyl is one such medication that clinicians often use to treat dystonia in people with cerebral palsy. OBJECTIVES To assess the effects of trihexyphenidyl in people with dystonic cerebral palsy, according to the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) domains of impairment, activity and participation. We also assessed the type and incidence of adverse effects in people taking the drug. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, eight other databases and two trials registers in May 2017, and we checked reference lists and citations to identify additional studies. SELECTION CRITERIA We included randomised controlled trials comparing oral trihexyphenidyl versus placebo for dystonia in cerebral palsy. We included studies in children and adults of any age with dystonic cerebral palsy, either in isolation or with the associated movement disorders of spasticity, ataxia, chorea, athetosis and/or hypotonia. We included studies regardless of whether or not the study authors specified the method used to diagnose dystonia in their study population. Primary outcomes were change in dystonia and adverse effects. Secondary outcomes were: activity, including mobility and upper limb function; participation in activities of daily living; pain; and quality of life. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified one study, which was set in Australia, that met the inclusion criteria. This was a randomised, double-blind, placebo-controlled, cross-over trial in 16 children (10 boys and 6 girls) with predominant dystonic cerebral palsy and a mean age of 9 years (standard deviation 4.3 years, range 2 to 17 years). We considered the trial to be at low risk of selection, performance, detection, attrition, reporting and other sources of bias. We rated the GRADE quality of the evidence as low.We found no difference in mean follow-up scores for change in dystonia as measured by the Barry Albright Dystonia Scale (BADS), which assesses eight body regions for dystonia on a 5-point scale (0 = none to 4 = severe), resulting in a total score of 0 to 32. The BADS score was 2.67 points higher (95% confidence interval (CI) -2.55 to 7.90; low-quality evidence), that is, worse dystonia, in the treated group. Trihexyphenidyl may be associated with an increased risk of adverse effects (risk ratio 2.54, 95% CI 1.38 to 4.67; low-quality evidence).There was no difference in mean follow-up scores for upper limb function as measured by the Quality of Upper Extremity Skills Test, which has four domains that collectively assess 36 items (each scored 1 or 2) and produces a total score of 0 to 100. The score in the treated group was 4.62 points lower (95% CI -10.98 to 20.22; low-quality evidence), corresponding to worse function, than in the control group. We found low-quality evidence for improved participation (as represented by higher scores) in the treated group in activities of daily living, as measured by three tools: 18.86 points higher (95% CI 5.68 to 32.03) for the Goal Attainment Scale (up to five functional goals scored on 5-point scale (-2 = much less than expected to +2 = much more than expected)), 2.91 points higher (95% CI 1.01 to 4.82) for the satisfaction subscale of the Canadian Occupational Performance Measure (COPM; satisfaction with performance in up to five problem areas scored on a 10-point scale (1 = not satisfied at all to 10 = extremely satisfied)), and 2.24 points higher (95% CI 0.64 to 3.84) for performance subscale of the COPM (performance in up to five problem areas scored on a 10-point scale (1 = not able to do to; 10 = able to do extremely well)).The study did not report on pain or quality of life. AUTHORS' CONCLUSIONS At present, there is insufficient evidence regarding the effectiveness of trihexyphenidyl for people with cerebral palsy for the outcomes of: change in dystonia, adverse effects, increased upper limb function and improved participation in activities of daily living. The study did not measure pain or quality of life. There is a need for larger randomised, controlled, multicentre trials that also examine the effect on pain and quality of life in order to determine the effectiveness of trihexyphenidyl for people with cerebral palsy.
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Affiliation(s)
- Adrienne R Harvey
- The Royal Children's HospitalDepartment of Neurodevelopment and Disability50 Flemington RoadParkvilleVictoriaAustralia3052
- Murdoch Childrens Research InstituteParkvilleAustralia
- The University of MelbourneDepartment of PaediatricsParkvilleVictoriaAustralia3010
| | - Louise B Baker
- The Royal Children's HospitalDepartment of Neurodevelopment and Disability50 Flemington RoadParkvilleVictoriaAustralia3052
- The Royal Children's HospitalPaediatric RehabilitationParkvilleAustralia
| | - Dinah Susan Reddihough
- The Royal Children's HospitalDepartment of Neurodevelopment and Disability50 Flemington RoadParkvilleVictoriaAustralia3052
- Murdoch Childrens Research InstituteParkvilleAustralia
- The University of MelbourneDepartment of PaediatricsParkvilleVictoriaAustralia3010
| | - Adam Scheinberg
- Murdoch Childrens Research InstituteParkvilleAustralia
- The Royal Children's HospitalPaediatric RehabilitationParkvilleAustralia
- Monash UniversityDepartment of PaediatricsClaytonAustralia3168
| | - Katrina Williams
- The Royal Children's HospitalDepartment of Neurodevelopment and Disability50 Flemington RoadParkvilleVictoriaAustralia3052
- Murdoch Childrens Research InstituteParkvilleAustralia
- The University of MelbourneDepartment of PaediatricsParkvilleVictoriaAustralia3010
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