Botulinum toxin treatment in upper limb spasticity: treatment consistency

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

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

[Multilevel botulinum toxin treatment in severe spastic forms of cerebral palsy (GMFCS IV-V)]

OBJECTIVE

To evaluate the most typical target muscles and dosages for the first and repeated botulinum toxin A (BTA) injections in cerebral palsy (CP) patients with severe motor deficit - GMFCS IV-V.

MATERIAL AND METHODS

A retrospective analysis of 677 protocols of the first and repeated Abobotulinumtoxin A (AboA) injections in 333 patients with CP GMFCS IV and V, aged 1 to 18 years, was carried out.

RESULTS

Ninety-seven percent of patients received multilevel injections. In the lower extremities the most typical target muscles were: m.gracilis - 221 (66.4%) patients, hip adductors - 164 (49.2%), medial hamstring - 144 (43.2%). In the upper extremities the most typical muscles were: m.pronator teres - 237 (71.2%) patients, m.biceps brachii+m.brachialis - 197 (59.2%). The total dosages of AboA and dosages for every target muscle were calculated. Several patients required high dosages (more than 30 U/kg of AboA). Higher dosages per kg were used in younger children and for repeated injections. The age-related evolution of spastic patterns was described. Adverse events were observed in 36 cases (5.3% of all injections).

CONCLUSION

The majority of patients with GMFCS IV-V required multilevel BTA injections in high dosages, especially in young age. Described selection of target muscles and dosages of AboA could be taken into account as a practical experience and reference for the BTA therapy in GMFCS IV-V patients.

Interventions to improve upper limb function for children with bilateral cerebral palsy: a systematic review

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.

Should botulinum toxin A injections be repeated in children with cerebral palsy? A systematic review

AIM

The aim of this study was to determine the effects of repeat botulinum toxin A (BoNT-A) injections in children with spastic cerebral palsy (CP) on the basis of a best evidence synthesis.

METHOD

This study included 13 original articles after searching the literature to retrieve information. We used the critical review form produced by McMaster University to determine the methodological quality of the studies, and then confirmed the levels of evidence from Sackett. The studies were also evaluated using the International Classification of Function, Disability and Health - Children and Youth Version (ICF-CY).

RESULTS

A total of 893 children with spastic CP who had been administered repeat BoNT-A injections were evaluated. The evidence level was II in four of the thirteen studies, III in four studies, and IV in five studies. The McMaster review form score was 14 in two studies, 13 in four studies, and 12 in seven studies. The results showed that repeat BoNT-A may be a safe and an effective approach. The first two injections/one repeat especially relieve spasticity and improve fine and gross motor activities.

INTERPRETATION

Future studies to investigate the effectiveness of repeat BoNT-A in children with spastic CP may be planned within the framework of the ICF-CY to include well-designed randomized controlled trials and those conducted on larger homogenous groups.

Short-term effect of botulinum toxin a injection on spastic equinovarus foot in cerebral palsy patients: a study using the foot pressure measurement system

Objective

To evaluate the therapeutic effect of botulinum toxin A (BTX-A) injection on spastic gastrocnemius (GCM) and tibialis posterior muscles (TPo) by using the foot pressure measurement system (FPMS).

Methods

Eighteen ambulatory CP patients were recruited in this study. BTX-A was injected into the GCM at a dose of 6-12 units/kg and TPo at a dose of 4-9 units/kg according to the severity of equinus and varus deformity. Foot contact pattern, pressure time integral (PTI), coronal index using the FPMS and Modified Ashworth Scale (MAS), and visual inspection of gait pattern were used for evaluation of the therapeutic effect of BTX-A injection. Clinical and FPMS data were statistically analyzed according to the muscle group.

Results

A significant decrease in the MAS score of the GCM and TPo was observed, and spastic equinovarus pattern during gait showed improvement after injection. The GCM+TPo injection group showed a significant decrease in forefoot, lateral forefoot pad, and lateral column PTI, and a significant increase in hindfoot PTI and coronal index. In the GCM only injection group, forefoot PTI and lateral column PTI were significantly decreased and hindfoot PTI was significantly increased. The TPo only injection group showed a significant decrease in lateral column PTI and a significant increase in the coronal index. Change in PTI in the hindfoot showed a significant correlation with the change in MAS score of the GCM. Change in PTI of the lateral column and coronal index showed a significant correlation with the change in MAS score of the TPo.

Conclusion

The FPMS demonstrated the quantitative therapeutic effect of BTX-A on abnormal pressure distribution in equinovarus foot in detail. The FPMS can be a useful additional tool for evaluation of the effect of BTX-A injection.