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Kumar Panda P, Moirangthem V, Tomar A, Neyaz O, Sharawat IK. Efficacy of Oral Trihexyphenidyl Plus Clonazepam Versus Trihexyphenidyl for the Treatment of Dystonia in Children With Dystonic Cerebral Palsy: An Open-Label Randomized Controlled Trial. Pediatr Neurol 2024; 158:35-40. [PMID: 38945037 DOI: 10.1016/j.pediatrneurol.2024.06.004] [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: 10/24/2023] [Revised: 05/13/2024] [Accepted: 06/09/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Trihexyphenidyl and clonazepam are commonly used to treat dystonia in children with cerebral palsy (CP). However, there is a notable gap in the literature when it comes to studies that combine these first-line agents for the management of dystonia. METHODS This open-label, randomized controlled trial aimed to compare the efficacy of adding oral clonazepam to trihexyphenidyl (THP + CLZ) versus using trihexyphenidyl alone (THP) in reducing the severity of dystonia, as measured by the Barry-Albright Dystonia (BAD) score. The study was conducted over a 12-week therapy period in children with dystonic CP aged two to 14 years. RESULTS Each group enrolled 51 participants. The THP + CLZ group showed significantly better improvement in dystonia severity at 12 weeks compared with the THP group alone (-4.5 ± 2.9 vs -3.4 ± 1.7, P = 0.02). Furthermore, the THP + CLZ group exhibited superior improvement in the severity of choreoathetosis, upper limb function, pain perception by the child, and quality of life, with P values of 0.02, 0.009, 0.01, and 0.01, respectively. The number of participants experiencing treatment-emergent adverse events was comparable in both groups (P = 0.67). Importantly, none of the participants in any of the groups reported any serious adverse events. CONCLUSION A combination of oral THP + CLZ proves to be more efficacious than using THP alone for the treatment of dystonic CP in children aged two to 14 years in terms of reducing the severity of dystonia.
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Affiliation(s)
- Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Vetoni Moirangthem
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Apurva Tomar
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Osama Neyaz
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
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Fehlings D, Agnew B, Gimeno H, Harvey A, Himmelmann K, Lin JP, Mink JW, Monbaliu E, Rice J, Bohn E, Falck-Ytter Y. Pharmacological and neurosurgical management of cerebral palsy and dystonia: Clinical practice guideline update. Dev Med Child Neurol 2024; 66:1133-1147. [PMID: 38640091 DOI: 10.1111/dmcn.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 04/21/2024]
Abstract
Dystonia, typically characterized by slow repetitive involuntary movements, stiff abnormal postures, and hypertonia, is common among individuals with cerebral palsy (CP). Dystonia can interfere with activities and have considerable impact on motor function, pain/comfort, and ease of caregiving. Although pharmacological and neurosurgical approaches are used clinically in individuals with CP and dystonia that is causing interference, evidence to support these options is limited. This clinical practice guideline update comprises 10 evidence-based recommendations on the use of pharmacological and neurosurgical interventions for individuals with CP and dystonia causing interference, developed by an international expert panel following the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The recommendations are intended to help inform clinicians in their use of these management options for individuals with CP and dystonia, and to guide a shared decision-making process in selecting a management approach that is aligned with the individual's and the family's values and preferences.
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Affiliation(s)
- Darcy Fehlings
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Brenda Agnew
- Family Advisor AACPDM, CP-NET, Burlington, Ontario, Canada
| | - Hortensia Gimeno
- Barts NHS Health and Queen Mary University of London, Wolfson Institute of Population Health, Centre for Preventive Neurology, London, UK
| | - Adrienne Harvey
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Faculty of Life Sciences & Medicine, King's Health Partners, Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Women's and Children's Health Institute, London, UK
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Elegast Monbaliu
- Neurorehabilitation Technology, Lab KU Leuven Campus Brugge, Brugge, Belgium
| | - James Rice
- Paediatric Rehabilitation Department, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Emma Bohn
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
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Kronlage RM, Fadil AB, Drew KL, Smith IB, Collins WO, Schrepfer T. Navigating the spectrum of pediatric sialorrhea management: A narrative review. Am J Otolaryngol 2024; 45:104433. [PMID: 39067093 DOI: 10.1016/j.amjoto.2024.104433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE This review summarizes the approaches to pediatric sialorrhea management from least-to-most invasive: non-pharmacological management, anticholinergic medications, botulinum neurotoxin, non-invasive surgery, and invasive surgical intervention. REVIEW METHODS An electronic literature review identified English-language articles on sialorrhea management in pediatric patients. Publications between 1982 and 2022 were used, with a focus on articles published from 2012 to 2022. Additional augmentation of pharmacologic information was obtained from the latest editions of medical textbooks supplemented with official package inserts of investigated medications. CONCLUSIONS Sialorrhea is abnormal in patients greater than four years of age. Severe cases warrant intervention to improve patient quality of life and reduce caregiver burden. Management starts with conservative approaches. Viable candidates begin with non-pharmacological management options. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus multiple treatments are required. Non-invasive sclerotherapy is an emerging treatment option showing promising results for sialorrhea. In contrast, surgical intervention is reserved as a last-resort treatment for patients with severe symptoms, due to its higher risk for adverse consequences. IMPLICATIONS FOR PRACTICE Physicians should be familiar with the different pediatric sialorrhea management options, including advantages and disadvantages, to adequately facilitate shared decision making with caretakers of pediatric patients who require treatment.
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Affiliation(s)
- René M Kronlage
- University of Florida College of Medicine, Gainesville, FL, USA.
| | - Angela B Fadil
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kristin L Drew
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Isaac B Smith
- University of Florida College of Medicine, Gainesville, FL, USA
| | - William O Collins
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Thomas Schrepfer
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
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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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Ishida N, Oshima Y, Katsura A, Imamura R, Arakawa H, Shimada T, Mizuno S, Sai Y, Suga Y, Matsushita R. Application Site of Transdermal Scopolamine Influences Efficacy and Drug Concentration in Salivary Glands in Rats. Biol Pharm Bull 2023; 46:1805-1809. [PMID: 38044099 DOI: 10.1248/bpb.b23-00561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Transdermal scopolamine applied to the postauricular area is used to treat drooling. We investigated the duration of action of scopolamine ointment and the effect of the application site on drug efficacy and concentration in the salivary glands of rats. Scopolamine ointment was applied to the skin over the salivary glands (SSG) and back (SB). Saliva volume was measured after intraperitoneal administration of pilocarpine. Blood and salivary glands were collected after scopolamine ointment application, and scopolamine concentrations in the plasma and salivary glands were measured. Saliva volume after application in the SSG group was significantly lower at all time points than in the non-treated group, and the change in saliva volume in the SSG group was greater than that in the SB group at all time points. This suggests that applying scopolamine ointment to the SSG strongly suppresses salivary secretion. Scopolamine concentration in the salivary glands of the SSG group was significantly higher at 9 h. The change in the efficacy of scopolamine ointment depending on the application site was due to the difference in transfer to the salivary glands. Transdermal administration of scopolamine to the skin over the salivary glands may have high efficiency in treating drooling.
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Affiliation(s)
- Natsuko Ishida
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Yoshitaka Oshima
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Ayano Katsura
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Rikako Imamura
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Hiroshi Arakawa
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Tsutomu Shimada
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University
- Department of Hospital Pharmacy, University Hospital, Kanazawa University
| | - Satoshi Mizuno
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University
| | - Yoshimichi Sai
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University
- Department of Hospital Pharmacy, University Hospital, Kanazawa University
| | - Yukio Suga
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
| | - Ryo Matsushita
- Department of Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University
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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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You P, Strychowsky J, Gandhi K, Chen BA. Anticholinergic treatment for sialorrhea in children: A systematic review. Paediatr Child Health 2022; 27:82-87. [PMID: 35599670 PMCID: PMC9113838 DOI: 10.1093/pch/pxab051] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/09/2021] [Indexed: 08/27/2023] Open
Abstract
Background Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious. Objective To examine the effectiveness of anticholinergic medications for sialorrhea in children. Methods A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized. Results The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis. Conclusions Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.
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Affiliation(s)
- Peng You
- Department of Otolaryngology - Head and Neck Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Julie Strychowsky
- Department of Otolaryngology - Head and Neck Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Karan Gandhi
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Breanna A Chen
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada
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Bohn E, Goren K, Switzer L, Falck‐Ytter Y, Fehlings D. Pharmacological and neurosurgical interventions for individuals with cerebral palsy and dystonia: a systematic review update and meta-analysis. Dev Med Child Neurol 2021; 63:1038-1050. [PMID: 33772789 PMCID: PMC8451898 DOI: 10.1111/dmcn.14874] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 12/30/2022]
Abstract
AIM To update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia. METHOD Searches were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE. RESULTS Nineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non-randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis. INTERPRETATION Evidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty. What this paper adds Meta-analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain. Meta-analysis suggests that DBS may improve motor function. Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals. ITB and DBS may improve quality of life. No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
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Affiliation(s)
- Emma Bohn
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Katherine Goren
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Lauren Switzer
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Yngve Falck‐Ytter
- Division of Gastroenterology and HepatologyVeteran Affairs North East Ohio Health Care SystemCase Western Reserve UniversityClevelandOHUSA
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
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Abstract
Identifying the subtypes of hypertonia is becoming increasingly important. Treatment strategies, including tone-modulating surgical interventions, medication type and dosing, and chemodenervation, may differ depending on the type of hypertonia present. It is important to delineate how hypertonia interferes with function and quality of life so that the appropriate intervention can be selected at the right time. Outcomes of treatment depend heavily on clear communication of goals. Botulinum toxin should not be used in isolation but as an adjunct to rehabilitation modalities.
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Affiliation(s)
- Rochelle Dy
- PM&R, Texas Children's Hospital, 6701 Fannin Street, Suite D1280, Houston, TX 77030, USA.
| | - Desiree Roge
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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11
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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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12
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Tailor the pharmacological management of childhood dystonia to meet the needs of each child. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Fehlings D, Brown L, Harvey A, Himmelmann K, Lin JP, Macintosh A, Mink JW, Monbaliu E, Rice J, Silver J, Switzer L, Walters I. Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:356-366. [PMID: 29405267 DOI: 10.1111/dmcn.13652] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 12/22/2022]
Abstract
AIM To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway. METHOD Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines. RESULTS Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin. INTERPRETATION For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion. WHAT THIS PAPER ADDS Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.
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Affiliation(s)
- Darcy Fehlings
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Leah Brown
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Parkville, Vic, Australia
| | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas', NHS Foundation Trust, Kings' Health Partners, London, UK
| | - Alexander Macintosh
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Elegast Monbaliu
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - James Rice
- Paediatric Rehabilitation Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Jessica Silver
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Lauren Switzer
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Ilana Walters
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
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Harvey A, Reddihough D, Scheinberg A, Williams K. Oral medication prescription practices of tertiary-based specialists for dystonia in children with cerebral palsy. J Paediatr Child Health 2018; 54:401-404. [PMID: 29105865 DOI: 10.1111/jpc.13754] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 08/11/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022]
Abstract
AIM To examine current clinical practice for prescribing medications for children with dystonic cerebral palsy (CP) by medical doctors working at a tertiary care centre. METHODS Rehabilitation and developmental paediatric specialists completed: (i) a custom-designed online cross-sectional survey capturing their usual prescribing patterns; and (ii) one-page questionnaires detailing medication prescription for each child with CP who they started on a new medication for dystonia over a 12-month period. RESULTS Eleven participating doctors ranged in experience in managing children with CP from less than 5 years to more than 20 years. The cross-sectional survey showed that most doctors used more than one medication, with six making choices taking into account four or more different medications. Oral baclofen was used by all doctors and was the first choice of 10 of 11. Prospective surveys from 57 children showed that medication was prescribed mainly for children aged 3-10 years (n = 35/57), classified within Gross Motor Function Classification System levels IV and V (n = 40/57) and with a mixed movement disorder (n = 38/57). Gabapentin and baclofen were the most frequently prescribed (n = 21/57 and 19/57, respectively), with other drugs used less frequently. Dosage regimens varied between and within doctors, particularly for the use of gabapentin and diazepam. CONCLUSIONS Oral medication prescribing practices varied among doctors managing children with dystonic CP at a tertiary care hospital, particularly with respect to dosing. There is a need for clinical guidelines for medication prescription to be developed based on best evidence and consensus by clinical experts.
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Affiliation(s)
- Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Dinah Reddihough
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Adam Scheinberg
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Victorian Paediatric Rehabilitation Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Katrina Williams
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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Masson R, Pagliano E, Baranello G. Efficacy of oral pharmacological treatments in dyskinetic cerebral palsy: a systematic review. Dev Med Child Neurol 2017; 59:1237-1248. [PMID: 28872668 DOI: 10.1111/dmcn.13532] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2017] [Indexed: 12/19/2022]
Abstract
AIM To evaluate the actual evidence of efficacy of oral pharmacological treatments in the management of dyskinetic cerebral palsy (CP). METHOD A systematic review was performed according to the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Articles were searched for in PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, Database of Reviews of Effectiveness, OTSeeker, Physiotherapy Evidence Database, REHABDATA, and ClinicalTrials.gov. RESULTS Sixteen articles met the eligibility criteria. Eight studies on trihexyphenidyl and two on levodopa showed contradictory results. Low efficacy was reported for diazepam, dantrolene sodium, perphenazine, and etybenzatropine. Tetrabenazine, gabapentin and levetiracetam should be studied in more detail. The updated available evidence does not support any therapeutic algorithm for the management of dyskinetic CP. INTERPRETATION This lack of evidence is partially owing to the inconsistency of classifications of patients and of outcome measures used in the reviewed studies. Further randomized, double-blind, placebo-controlled pharmacological trials, optimized for different age groups, based on valid, reliable, and disease-specific rating scales are strongly needed. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health. WHAT THIS PAPER ADDS Evidence to prove (or disprove) the efficacy of oral drugs in dyskinetic cerebral palsy is low. The most investigated drugs, trihexyphenidyl and levodopa, show contradictory results. Tetrabenazine, levetiracetam, and gabapentin efficacy should be studied in more detail. Lack of evidence is partially due to the inconsistency of classifications and outcome measures used. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health in next clinical trials.
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Affiliation(s)
- Riccardo Masson
- Developmental Neurology Unit, "Carlo Besta" Neurological Institute Foundation, Milan, Italy
| | - Emanuela Pagliano
- Developmental Neurology Unit, "Carlo Besta" Neurological Institute Foundation, Milan, Italy
| | - Giovanni Baranello
- Developmental Neurology Unit, "Carlo Besta" Neurological Institute Foundation, Milan, Italy
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Abstract
Dystonia is one of the most frequent movement disorders in childhood. It can impede normal motor development and cause significant motor disability. The diagnostic evaluation of childhood dystonia is challenging due to the phenotypic variability and heterogeneous etiologies. Evidence to guide the diagnostic evaluation and treatment is limited. Assessment is primarily directed by clinical history and distinctive examination findings. Neuroimaging is typically necessary to evaluate for acquired or complex inherited dystonias. A trial of levodopa can be both diagnostic and therapeutic in children with dopa-responsive dystonia. However, for the majority of children with early-onset dystonia, treatment is symptomatic with varying efficacy. There is a paucity of therapeutic trials for childhood dystonia and most treatment recommendations are consensus or expert opinion driven. This review summarizes the available evidence and guidelines on the diagnostic evaluation and pharmacological treatment of childhood-onset dystonia and provides practical frameworks to approach both issues based on best evidence.
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Dias BLS, Fernandes AR, Maia Filho HDS. Treatment of drooling with sublingual atropine sulfate in children and adolescents with cerebral palsy. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:282-287. [DOI: 10.1590/0004-282x20170033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/20/2016] [Indexed: 11/21/2022]
Abstract
ABSTRACT Atropine sulfate blocks the muscarinic receptors in the salivary glands and leads to reduced saliva production. There are no published studies about its use in children with cerebral palsy. Objective To report the effect of sublingual atropine sulfate to treat drooling in children with cerebral palsy by comparing the results of the Drooling Impact Scale in a non-controlled open clinical trial. Results Twenty-five children were assessed. The difference in the mean scores of the pre- and post-treatment scales reached statistical significance. There was a low frequency of side effects compared to studies with other anticholinergics. Conclusion The use of sublingual atropine sulfate seems to be safe and there is a reduction in the Drooling Impact Scale score, which suggests efficacy in the treatment of drooling in children and adolescents with cerebral palsy. Our results should be replicated in randomized, placebo-controlled studies with larger numbers of participants.
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Termsarasab P, Thammongkolchai T, Frucht SJ. Medical treatment of dystonia. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2016; 3:19. [PMID: 28031858 PMCID: PMC5168853 DOI: 10.1186/s40734-016-0047-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/08/2016] [Indexed: 11/25/2022]
Abstract
Therapeutic strategies in dystonia have evolved considerably in the past few decades. Three major treatment modalities include oral medications, botulinum toxin injections and surgical therapies, particularly deep brain stimulation. Although there has been a tremendous interest in the later two modalities, there are relatively few recent reviews of oral treatment. We review the medical treatment of dystonia, focusing on three major neurotransmitter systems: cholinergic, GABAergic and dopaminergic. We also provide a practical guide to medication selection, therapeutic strategy and unmet needs.
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Affiliation(s)
- Pichet Termsarasab
- Movement Disorder Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Steven J. Frucht
- Movement Disorder Division, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
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Dias BLS, Fernandes AR, Maia Filho HDS. Sialorrhea in children with cerebral palsy. J Pediatr (Rio J) 2016; 92:549-558. [PMID: 27281791 DOI: 10.1016/j.jped.2016.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To review the literature on sialorrhea in children with cerebral palsy. SOURCE OF DATA Non-systematic review using the keywords "sialorrhea" and "child" carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed. DATA SYNTHESIS The prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment. CONCLUSIONS The most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.
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Affiliation(s)
| | | | - Heber de Souza Maia Filho
- Universidade Federal Fluminense (UFF), Programa de Mestrado Profissional em Saúde Materno-Infantil, Niterói, RJ, Brazil
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Scofano Dias BL, Fernandes AR, Maia Filho HDS. Sialorrhea in children with cerebral palsy. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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van den Heuvel CNAM, Tijssen MAJ, van de Warrenburg BPC, Delnooz CCS. The Symptomatic Treatment of Acquired Dystonia: A Systematic Review. Mov Disord Clin Pract 2016; 3:548-558. [PMID: 30363468 DOI: 10.1002/mdc3.12400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/12/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Acquired dystonia is caused by an acquired or exogenous event. Although the therapeutic armamentarium used in clinical practice is more or less similar to that used for inherited or idiopathic dystonia, formal proof of the efficacy of these interventions in acquired dystonia is lacking. Methods The authors attempt to provide a comprehensive and systematic review of the current evidence for medical and allied health care treatment strategies in acquired dystonias. The PubMed, Cochrane Library, MEDLINE, Web of Science, PiCarta, and PsycINFO databases were searched up to December 2015, including randomized controlled trials, patient-control studies, and case series or single case reports containing a report on clinical outcome. Results There are level 3 practice recommendations for botulinum toxin injections and globus pallidus pars interna deep brain stimulation for tardive dystonia and dystonic cerebral palsy as well as intrathecal baclofen for dystonic cerebral palsy. There are insufficient and conflicting data on the effect (vs. the hazard) of other pharmacological interventions, and limited work has been done on other forms of neurostimulation and allied health care. Because no class A1 or A2 studies were identified, level 1 or 2 practice recommendations could not be deducted for a specific treatment intervention. Conclusions To improve the current medical and allied health care treatment options for patients with acquired dystonia, high-quality trials that examine the efficacy of therapies need to be performed.
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Affiliation(s)
- Corina N A M van den Heuvel
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Marina A J Tijssen
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
| | - Bart P C van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Cathérine C S Delnooz
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
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Begbie F, Walker G, Kubba H, Sabharwal A. Acute colonic pseudo-obstruction in a child taking trihexyphenidyl for drooling: Prescribers beware. Int J Pediatr Otorhinolaryngol 2015; 79:932-934. [PMID: 25912627 DOI: 10.1016/j.ijporl.2015.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/25/2015] [Accepted: 03/28/2015] [Indexed: 11/17/2022]
Abstract
Colonic pseudo-obstruction (Ogilvie's Syndrome) in children is relatively uncommon. We report an unusual case of colonic pseudo-obstruction in an 8-year-old child with cerebral palsy and long-term hypomotility issues being treated for drooling with the anticholinergic medication trihexyphenidyl. He presented as an emergency with severe abdominal distension, abdominal tenderness and vomiting. An emergency laparotomy revealed colonic dilatation and a defunctioning ileostomy was created. To our knowledge, this is the first case reporting colonic pseudo-obstruction as a possible complication of treatment with trihexyphenidyl. We suggest prescribers should exercise caution when prescribing trihexyphenidyl in patients with long-term intestinal hypomotility issues.
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Affiliation(s)
- F Begbie
- Department of Paediatric Otolaryngology, Yorkhill Children's Hospital, Glasgow, United Kingdom.
| | - G Walker
- Department of Paediatric Surgery, Yorkhill Children's Hospital, Glasgow, United Kingdom
| | - H Kubba
- Department of Paediatric Otolaryngology, Yorkhill Children's Hospital, Glasgow, United Kingdom
| | - A Sabharwal
- Department of Paediatric Surgery, Yorkhill Children's Hospital, Glasgow, United Kingdom
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Rasmussen LA, Grégoire MC. Challenging neurological symptoms in paediatric palliative care: An approach to symptom evaluation and management in children with neurological impairment. Paediatr Child Health 2015; 20:159-65. [PMID: 25914579 PMCID: PMC4403283 DOI: 10.1093/pch/20.3.159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 11/13/2022] Open
Abstract
Neurological symptoms are very common in children with life-limiting conditions and are challenging in terms of burden of illness. Moreover, neurological symptoms can significantly impact the child's quality of life and contribute to distress among parents, families, caregivers and health care providers. Knowing how to manage and alleviated these symptoms is essential for providing good palliative care. In the present article, the more common neurological symptoms of agitation/irritability, spasticity and dystonia will be reviewed. The aim of the present brief review is to provide a basic approach to both the identification and treatment of these neurological symptoms. A medication table is provided for quick reference. A brief commentary and guidance for the management of pain are also incorporated, with reference to further literature sources.
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Affiliation(s)
- Lisa Ann Rasmussen
- Department of Paediatrics, McGill University/Montreal Children's Hospital, Montreal, Quebec
| | - Marie-Claude Grégoire
- Department of Paediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia
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Abstract
The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2-3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.
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Affiliation(s)
- Allan Colver
- Institute of Health and Society, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Charles Fairhurst
- Department of Paediatric Neurosciences, Evelina Children's Hospital, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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Penner M, Xie WY, Binepal N, Switzer L, Fehlings D. Characteristics of pain in children and youth with cerebral palsy. Pediatrics 2013; 132:e407-13. [PMID: 23858420 DOI: 10.1542/peds.2013-0224] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Pain in children with cerebral palsy (CP) is underrecognized, undertreated, and negatively affects quality of life. Communication challenges and multiple pain etiologies complicate diagnosis and treatment. The primary objectives of this study were to determine the impact of pain on activities and to identify the common physician-identified causes of pain in children and youth ages 3 to 19 years across all levels of severity of CP. METHODS The study design was cross-sectional, whereby children/youth aged 3 to 19 years and their families were consecutively recruited. The primary caregivers were asked to complete a one-time questionnaire, including the Health Utilities Index 3 pain subset, about the presence and characteristics of pain. The treating physician was asked to identify the presence of pain and provide a clinical diagnosis for the pain, if applicable. RESULTS The response rate was 92%. Of 252 participants, 54.8% reported some pain on the Health Utilities Index 3, with 24.4% of the caregivers reporting that their child experienced pain that affected some level of activities in the preceding 2 weeks. Physicians reported pain in 38.7% and identified hip dislocation/subluxation, dystonia, and constipation as the most frequent causes of pain. CONCLUSIONS One-quarter of our sample experienced pain that limited activities and participation. Clinicians should be aware that hip subluxation/dislocation and dystonia were the most common causes of pain in children/youth with CP in this study. Potential causes of pain should be identified and addressed early to mitigate the negative impact of pain on quality of life.
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Affiliation(s)
- Melanie Penner
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Updates in the Treatment of Spasticity Associated With Cerebral Palsy. Curr Treat Options Neurol 2012; 14:650-9. [DOI: 10.1007/s11940-012-0192-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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García Ron A, Miranda MC, Garriga Braun C, Jensen Verón J, Torrens Martinez J, Diez Hanbino MP. [Efficacy and safety of botulinum toxin in the treatment of sialorrhea in children with neurological disorders]. An Pediatr (Barc) 2012; 77:289-91. [PMID: 22652186 DOI: 10.1016/j.anpedi.2012.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/29/2012] [Accepted: 03/31/2012] [Indexed: 10/28/2022] Open
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Moustafa AM, Ghanem AEAA. Effect of acute trihexyphenidyl abuse on rat motor area of cerebral cortex. THE EGYPTIAN JOURNAL OF HISTOLOGY 2011; 34:687-696. [DOI: 10.1097/01.ehx.0000406546.11293.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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