Use of botulinum toxin injection in 17 children with spastic cerebral palsy

The utility of shear wave elastography in the evaluation of muscle stiffness in patients with cerebral palsy after botulinum toxin A injection

PURPOSE

The first aim of this study was to evaluate changes in the stiffness of the medial gastrocnemius muscle (GM) after a botulinum toxin A (BoNT-A) injection in children with cerebral palsy (CP) using shear wave elastography (SWE). We also wanted to investigate the usability of SWE for evaluating spasticity in a clinical setting. The second aim of this study was to show how treatment of the gastrocnemius muscle spasticity caused a change in the elasticity of the anterior tibial (TA) muscle.

METHODS

Twenty-four pediatric patients diagnosed with a spastic type of CP, who were scheduled to receive a BoNT-A injection in the gastrocnemius muscle, were included in the study. There was a total of 43 lower extremities to evaluate, and muscle stiffness was measured before the injection and a month post injection using SWE. The physiatrist evaluated muscle spasticity using the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale at about the same time.

RESULTS

SWE values of the GM (pre-BoNT-A: 45.9 ± 6.5 kPa, post-BoNT-A: 25.0 ± 5.7 kPa) decreased significantly post BoNT-A injection (P < 0.01). SWE measurements of the GM had positive correlations with MAS, V1X, V3X, and R2-R1 (P < 0.01); and negative correlations with R2 and R1 (P < 0.05). SWE values of the TA muscle (pre: 36.9 ± 7.9 kPa, post: 28.4 ± 5.2 kPa) decreased significantly (P < 0.01).

CONCLUSION

Quantitative measurement of muscle stiffness using SWE may provide important information for the evaluation of spasticity and treatment efficiency in pediatric CP patients.

Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disabilities in children in high-income countries. Spasticity is the most common motor disturbance in CP. Botulinum toxin type A (BoNT-A) is considered the first-line treatment for focal spasticity in people with CP.

OBJECTIVES

To evaluate the effectiveness and safety of BoNT-A compared to other treatments used in the management of lower limb spasticity in children with CP.

SEARCH METHODS

We searched CENTRAL, PubMed, four other databases, and two trial registers in October 2018. We also searched the reference lists of relevant studies and reviews and contacted experts in the field. We did not apply any date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials of children with CP, aged between birth and 19 years, treated with BoNT-A injections in the lower limb muscles compared to other interventions. The primary outcomes were gait analysis and function. The secondary outcomes were joint range of motion, quality of life, satisfaction, spasticity, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risk of bias, and rated the quality of the evidence using GRADE. A third review author arbitrated in case of disagreements. We conducted meta-analyses of available data whenever possible, analysing dichotomous data with risk ratios (RR), and continuous data with mean differences (MD) or standardised mean differences (SMD), with 95% confidence intervals (CI). We considered a 5% significance level for all analyses.Whenever possible, we analysed outcomes at the time points at which they were assessed: short term (2 to 8 weeks); medium term (12 to 16 weeks); and long term (> 24 weeks).

MAIN RESULTS

We included 31 randomised controlled trials assessing 1508 participants. Most studies included ambulatory patients with more than one motor type of CP, and with a mean age of between three and seven years. There was a slight predominance of males.Studies compared BoNT-A in the lower limb muscles to usual care or physiotherapy (14 studies), placebo or sham (12 studies), serial casting (4 studies), or orthoses (1 study).We rated studies as at high or unclear risk of bias mainly due to random sequence generation, allocation concealment, blinding of participants and personnel, and blinding of outcome assessment.BoNT-A versus usual care or physiotherapyBoNT-A might improve overall gait scores at medium-term follow-up (MD 2.80, 95% CI 1.55 to 4.05; 1 study, 40 children; very low-quality evidence) and is moderately effective at improving function at short-term (SMD 0.59, 95% CI 0.23 to 0.95; 2 studies, 123 children) and medium-term (SMD 1.04, 95% CI 0.16 to 1.91; 4 studies, 191 children) follow-up (all very low-quality evidence).BoNT-A improves ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (very low-quality evidence).The proportion of adverse events in the BoNT-A group was 0.37 (95% CI 0.08 to 0.66; I² = 95%; very low-quality evidence). No adverse events were reported in the control group.BoNT-A versus placebo or shamBoNT-A improves overall gait scores at short-term (RR 1.66, 95% CI 1.16 to 2.37, P = 0.006; 4 studies, 261 assessments) and medium-term (RR 1.90, 95% CI 1.32 to 2.74, P < 0.001; 3 studies, 248 assessments) follow-up, and may improve peak ankle dorsiflexion in stance (MD 15.90 degrees, 95% CI 4.87 to 26.93, P = 0.005; 1 study, 19 children) and in swing (MD 10.20 degrees, 95% CI 4.01 to 16.39, P = 0.001; 1 study, 19 children) at short-term follow-up (all moderate-quality evidence).BoNT-A is not more effective than placebo or sham at improving function at short-term (SMD 0.24, 95% CI -0.35 to 0.83, P = 0.42; 4 studies, 305 children) or long-term (SMD -0.07, 95% CI -0.48 to 0.35, P = 0.76; 2 studies, 91 children) follow-up, but has a small positive effect at medium-term follow-up (SMD 0.28, 95% CI 0.06 to 0.49, P = 0.01; 5 studies, 327 children) (all moderate-quality evidence).BoNT-A improves passive ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (moderate-quality evidence).There was no difference between groups in the rate of adverse events at short-term follow-up (RR 1.29, 95% CI 0.87 to 1.93, P = 0.21; 12 studies, 918 children; moderate-quality evidence).BoNT-A versus serial castingThere was no difference between groups for overall gait scores at short-term (MD 0.00, 95% CI -1.66 to 1.66); medium-term (MD 0.65, 95% CI -1.21 to 2.51); or long-term (MD 0.46, 95% CI -1.33 to 2.25) follow-up in one study with 18 children (moderate-quality evidence).BoNT-A improved instrumented gait analysis only in terms of ankle dorsiflexion at initial contact (MD 6.59 degrees, 95% CI 1.39 to 11.78, P = 0.01; 2 studies, 47 children). There was no difference between groups for peak ankle dorsiflexion in stance and swing, and gait speed at any time point (moderate- and low-quality evidence).BoNT-A is not more effective than serial casting at improving function, ankle range of motion, and spasticity at any time point (moderate- and low-quality evidence).BoNT-A is not associated with a higher risk of adverse events than serial casting (RR 0.59, 95% CI 0.03 to 11.03; 3 studies, 64 children; low-quality evidence).BoNT-A versus orthosesThere was no difference between groups for function at medium-term follow-up (MD 11.14, 95% CI -0.05 to 22.33; 1 study, 43 children), but BoNT-A is more effective than orthoses at improving hip range of motion and hip adductors spasticity (all very low-quality evidence).

AUTHORS' CONCLUSIONS

The quality of the evidence was low or very low for most of the outcomes analysed. We found limited evidence that BoNT-A is more effective than placebo or a non-placebo control at improving gait, joint range of motion, satisfaction, and lower limb spasticity in children with CP, whereas the results for function were contradictory. The rate of adverse events with BoNT-A is similar to placebo. BoNT-A is not more effective than ankle serial casting to treat ankle contractures for any of the assessed outcomes, but is more effective than orthotics at improving range of motion and spasticity.

Phenol Versus Botulinum Toxin A Injection in Ambulatory Cerebral Palsy Spastic Diplegia: A Comparative Study

The aim of this study is to compare the treatment effectiveness of botulinum toxin type A (BTX-A) and phenol blocks in the management of lower limb spasticity and to measure improvement in gross motor functional outcome in children with cerebral palsy (CP). This is a hospital-based prospective, noncontrolled randomized study that took place in a tertiary care center. A total of 61 ambulatory children with CP spastic diplegia, aged from 4 to 10 years, were randomly divided into two groups and included in this study. Twenty-eight children with CP received BTX-A injections and 33 received phenol motor point blocks. The measures performed were as follows: outcome assessment spasticity by the Modified Ashworth scale (MAS), active range of motion (AROM) of lower limb joint by goniometer, and functional improvement by Gross Motor Function Measures (GMFM). Postinjection follow-up done at 2, 6, 12, 24, and 48 weeks. Significant improvement in reduction of spasticity, increased AROM of all joints of lower limbs, and improvement in functional outcome were observed in CP with spastic diplegia after BTX-A injections as compared with the phenol motor point block group. There was no significant side effect after BTX-A injections as compared with phenol injections. BTX-A injections showed superior treatment effects in the reduction of spasticity and improvement in AROM and functional outcome measures with spastic diplegia as compared with phenol blocks. BTX-A injections also revealed fewer clinical side effects and were well tolerated by children with CP.

The effects of botulinum toxin type A on improvement and dynamic spastic equinus correction in children with cerebral palsy - preliminary results

INTRODUCTION

We evaluated the effects of botulinum toxin type A (BTA) with physical therapy on dynamic foot equinus correction and higher motor functional outcome in children with spastic type of cerebral palsy (CP).

MATERIAL AND METHODS

Ankle joint active and passive movement, gastrocnemial muscle spasticity levels (Modified Ashworth Scale (MAS)), and higher motor functional status (Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM) (GMFM-D - standing and GMFM-E - walking) were assessed before treatment and 3, 8, 16 weeks and 6 months after BTA administration in 12 children.

RESULTS

There was a significant improvement of active (initial - (-)13.07 ±5.78; 6 months - (-)10.64 ±4.77; p < 0.001) and passive (initial - 4.21 ±2.29; 6 months - 4.71 ±2.16; p < 0.05) ankle joint foot dorsiflexion. GMFM-D and GMFM-E were significantly higher after 3, 8, 16 weeks (p < 0.001) and GMFM-D after 6 months (p < 0.001).

CONCLUSIONS

Botulinum toxin type A administration and physical therapy in patients with spastic CP improves the motion range of dynamic foot equinus after 3 weeks and higher motor functional outcome (standing and walking).

The developing shoulder has a limited capacity to recover after a short duration of neonatal paralysis

Mechanical stimuli are required for the proper development of the musculoskeletal system. Removal of muscle forces during fetal or early post-natal timepoints impairs the formation of bone, tendon, and their attachment (the enthesis). The goal of the current study was to examine the capacity of the shoulder to recover after a short duration of neonatal rotator cuff paralysis, a condition mimicking the clinical condition neonatal brachial plexus palsy. We asked if reapplication of muscle load to a transiently paralyzed muscle would allow for full recovery of tissue properties. CD-1 mice were injected with botulinum toxin A to paralyze the supraspinatus muscle from birth through 2 weeks and subsequently allowed to recover. The biomechanics of the enthesis was determined using tensile testing and the morphology of the shoulder joint was determined using microcomputed tomography and histology. A recovery period of at least 10 weeks was required to achieve control properties, demonstrating a limited capacity of the shoulder to recover after only two weeks of muscle paralysis. Although care must be taken when extrapolating results from an animal model to the human condition, the results of the current study imply that treatment of neonatal brachial plexus palsy should be aggressive, as even short periods of paralysis could lead to long-term deficiencies in enthesis biomechanics and shoulder morphology.

Efficacy of botulinum toxin A in children with cerebral palsy in Gross Motor Function Classification System levels IV and V: a systematic review

AIM

Previous studies have shown the efficacy of botulinum toxin type A (BoNT-A) in the management of ambulant individuals with cerebral palsy (CP). There is little evidence on its use in non-ambulant children with CP. This review aimed to investigate indications and efficacy for BoNT-A use in managing pain, care, and comfort, and improving function in children with CP in Gross Motor Function Classification System (GMFCS) levels IV and V.

METHOD

Electronic databases were searched from the earliest available date to June 2012 using a combination of subject headings and free text. Inclusion criteria consisted of studies with (1) participants aged 18 or under, (2) participants with CP in GMFCS levels IV and V, (3) participants receiving BoNT-A treatment, and (4) studies published in English-language peer-reviewed journals.

RESULTS

The search resulted in a total of 814 studies, of which 19 met the inclusion criteria. Eighteen studies provided level IV or V evidence and one level I evidence according to the American Academy for Cerebral Palsy and Developmental Medicine guidelines for the development of systematic reviews. Most of the studies were of weak to moderate methodological quality.

INTERPRETATION

The evidence that BoNT-A is effective in reducing postoperative pain in children with CP in GMCFS levels IV and V is limited, with only one level I study identified. Remaining indications were general pain reduction, maintaining hip integrity, achieving functional changes, and goal attainment. A high percentage of participants in the studies showed positive changes in these areas. With the poor level of evidence of the included studies, no definite conclusion could be drawn on the indications for BoNT-A use in children with CP in GMCFS levels IV and V. Further investigation by rigorous studies is required.

Influence of botulinum toxin therapy on postural control and lower limb intersegmental coordination in children with spastic cerebral palsy

Botulinum toxin injections may significantly improve lower limb kinematics in gait of children with spastic forms of cerebral palsy. Here we aimed to analyze the effect of lower limb botulinum toxin injections on trunk postural control and lower limb intralimb (intersegmental) coordination in children with spastic diplegia or spastic hemiplegia (GMFCS I or II). We recorded tridimensional trunk kinematics and thigh, shank and foot elevation angles in fourteen 3-12 year-old children with spastic diplegia and 14 with spastic hemiplegia while walking either barefoot or with ankle-foot orthoses (AFO) before and after botulinum toxin infiltration according to a management protocol. We found significantly greater trunk excursions in the transverse plane (barefoot condition) and in the frontal plane (AFO condition). Intralimb coordination showed significant differences only in the barefoot condition, suggesting that reducing the degrees of freedom may limit the emergence of selective coordination. Minimal relative phase analysis showed differences between the groups (diplegia and hemiplegia) but there were no significant alterations unless the children wore AFO. We conclude that botulinum toxin injection in lower limb spastic muscles leads to changes in motor planning, including through interference with trunk stability, but a combination of therapies (orthoses and physical therapy) is needed in order to learn new motor strategies.

Long-term use of botulinum toxin type A in children with cerebral palsy: treatment consistency

At the University Hospital of Pellenberg (Belgium), more than 1000 patients have been treated with Botulinum toxin type A (BTX-A) over the last decade. Ten percent of these patients (n=106) received multiple (at least four times), multi-level, high-dosage treatments. The aim of this study was to evaluate the stability of dosage and treatment intervals in long-term, multi-level, high-dosage treated children with cerebral palsy and to evaluate the evidence for a safe and stable response to this treatment. Data on disease, age, dosage and target muscles were extracted for each treatment session of 106 patients who received multiple BTX-A treatment sessions. Patients had a follow-up of 4y 6mo (range 1y 8mo-8y 9mo) on average and received 4 to 12 BTX-A treatments within the period of January 1996 and December 2005. Patients received a mean dosage of 23.5+/-5.2U/kgbw at first treatment with stable subsequent values. Mean dosages for children with diplegia, hemiplegia and quadriplegia were 24.5+/-4.7U/kgbw, 15.9+/-3.7U/kgbw and 22.0+/-4.8U/kgbw, respectively. Mean age at first treatment was 4y 6mo (range 1y 11mo-18y 10mo) with a majority of patients (76.4%) first treated within 2 and 4y of age. Treatment intervals of approximately 1y remained stable within four, five and six subsequent treatments. Long-term, high-dosage, multi-level BTX-A applications can be considered as a safe and stable treatment option for children with cerebral palsy and the formation of antibodies, responsible for secondary non-response, can be indirectly precluded.

Recovery potential after postnatal shoulder paralysis. An animal model of neonatal brachial plexus palsy

BACKGROUND

Injury to the brachial plexus during birth results in paralysis of the upper extremity in as many as one in 250 births and can lead to substantial functional deficits in the shoulder. The goal of this study was to characterize the development of bone and joint deformities in paralyzed neonatal shoulders and to assess the improvement of these deformities after muscle function recovery with use of an animal model.

METHODS

Intramuscular injections of botulinum toxin were used to paralyze the supraspinatus, infraspinatus, and posterior deltoid of the left shoulders of mice at birth. Seventy mice were divided into three groups: Botox, recovery, and normal. The twenty-five mice in the Botox group received botulinum toxin injections until they were killed. The twenty mice in the recovery group received botulinum toxin injections for different durations and then were allowed injection-free recovery periods until they were killed. The twenty-five mice in the normal group received saline solution injections until they were killed. Radiographs were used to measure shoulder and elbow contractures. Microcomputed tomography was used to examine anatomical parameters of the supraspinatus muscle, humerus, and scapula.

RESULTS

The Botox group showed bone and joint deformities including delayed mineralization and flattening of the humeral head, hypoplasia, and introversion (i.e., anteversion) of the humerus, contractures of the shoulder and elbow, hypoplasia of shoulder muscles, hypoplasia of the scapula, and hypoplasia and retroversion of the glenoid. In the recovery group, a significant trend toward normal properties was observed with longer recovery periods (p<0.05). However, only soft-tissue contractures of the shoulder and elbow were resolved completely with the longest recovery period.

CONCLUSIONS

This mouse model successfully simulates human neonatal brachial plexus palsy, reproducing most of the bone and joint deformities found in the human condition. The deformities started to develop early in the postnatal period in the paralyzed shoulders and progressed with longer durations of paralysis. Early restoration of muscle function completely resolved the soft-tissue contractures of the shoulder and elbow. However, osseous deformities of the humerus and scapula were never resolved completely. These findings demonstrate the time-dependence of reversibility of musculoskeletal deformities in developing shoulders with neurological deficits.

Prospective study examining remote effects of botulinum toxin a in children with cerebral palsy

We examined the remote effects on muscle strength and functional decline of lower-extremity botulinum toxin A injections in children with cerebral palsy. This prospective study enrolled 34 children (19 boys, 15 girls; mean age, 7.7 years) diagnosed with spastic cerebral palsy. Patients were examined at baseline and 1 month to determine if they experienced a change in upper-extremity strength (handheld dynamometry) or function (Pediatric Outcomes Data Collection Instrument). Subjects were analyzed in aggregate and by dosing group (low dose, 0-10 U/kg body weight; high dose, 11-25 U/kg) to determine if injection dose was associated with a change in remote muscle strength or function. We measured baseline and 1-month postinjection strength in shoulder flexor, shoulder abductor, elbow flexor, elbow extensor, and finger flexor muscles. None of these remote muscle groups was significantly weaker at 1 month after injection. No correlation was evident between change in muscle strength and toxin dose. These findings indicate that doses of botulinum toxin A in the lower extremities, at up to 21 U/kg, do not affect upper-extremity strength. This information can help guide dosages of botulinum toxin A in the management of spasticity in children with cerebral palsy.

Long-term effect of repeated injections of botulinum toxin in children with cerebral palsy: a prospective study

PURPOSE

To prospectively evaluate long-term effects of repeated botulinum toxin A (BTX-A) injections in children with cerebral palsy (CP).

METHODS

Repeated injections of BTX-A were offered to children with CP, according to clinical indications, for a maximum of four injections within a period of two years. Injections were administered into lower extremity muscles of 26 consecutive children (age 3.7 +/- 1.2 years, 16 boys) with hemiplegic or diplegic CP. Clinical assessments before and one month following each injection included a gross motor function measure (GMFM), a modified Ashworth scale, and range-of-motion of knee extension and ankle dorsiflexion.

RESULTS

Twelve children received two injections, six received three injections, five received one injection, and three received four injections. The most common reason for discontinuing treatment was the need for orthopedic surgery (n = 17). A long-term effect was demonstrated by a significant increase of the GMFM score before the first injection compared with the last injection for each patient (P < 0.0001). There was no comparable change in the muscle tone or range-of-motion. The mean rate of GMFM change during the study was significantly higher than literature norms for CP children (13.2 vs. 5.37 per year, respectively, P < 0.01). The increase of the GMFM score before and one-month after injection (short-term effect) was significantly higher after the first injection than after the last injection (P < 0.05). Similar results were found for the Ashworth scale and popliteal angle.

CONCLUSIONS

Botulinum toxin A injections have a long-term effect on gross motor function in children with CP even though the effect on muscle tone is short-term. The effect apparently declines with repeated injections, with most children benefitting from 2 to 3 injections.

[Botulinum toxin type A for the treatment of spasticity in children with cerebral palsy]

BACKGROUND/AIM

Cerebral palsy (CP) is the most common physical disability in childhood. Children have problems with motor functions as a result of limbs spasticity, which leads to severe contractures and limbs deformity. There is a growing interest in the therapeutic role of botulinum toxin type A (BTA) in CP. The aim of this study was to examine the effects of BTA on spasticity, active range of motion and functional motor outcomes in children with CP.

METHODS

This study included 42 children of both sexes, aged 2-6 years, with spastic CP, divided into two groups: group I (21 child) treated with BTA and physical therapy, and group II (21 child) treated with physical therapy only. The following parameters were analyzed: spasticity; active range of motion of the hip, knee and ankle, and functional motor outcome. These parameters measurements were carried out four times in both groups: before the treatment, three, eight and 16 weeks after the beginning of the treatment. The obtained results were statistically processed and compared.

RESULTS

There was no evidence of any significant difference between the groups before the treatment. After eight weeks there was a remarkable difference concerning spasticity reducing on behalf of the group I (group I -- 0.76 +/- 0.51 vs. II group -- 2.17 +/- 0.64; p < 0.0001). There was statistically significant difference concerning active range of motion increasing on behalf of the group I (hip abduction: group I --44.37 +/- 1.13(0) vs. group II -- 32.61 +/- 8.07(0),p < 0,01; knee extension: group I -- 0.77 +/- 1.82(0) vs. II group -- 14.99 +/- 7.61(0), p < 0.01; dorsiflexion of the foot: group I -- 11.50 +/- 6.08(0) vs. group II -- 8.98 +/- 7.85(0), p < 0.01). A statistically significant difference was found after 16 weeks in functional motor outcome as well, on behalf of the group I: functional motor abilities level in the group I was 1.86 vs. 2.71 in the group II, p < 0.05.

CONCLUSION

Botulinum toxin type A application leads to an important spasticity decreasing, active range of motion increasing, as well as to functional abilities in children with CP.

Botulinum toxin A injection for spasticity in diplegic-type cerebral palsy

Botulinum toxin type A can be both safe and effective in relieving spasticity in pediatric patients with cerebral palsy. In our prospective study, we evaluated the functional effect of botulinum toxin A in spastic diplegic-type cerebral palsy. Patients were examined on enrollment and at 1, 3, and 6 months after injection. Passive dorsiflexion of the ankle joint was measured using a goniometer as an angle of possible maximal dorsiflexion with the knee extended and flexed. Spasticity was graded using the Modified Ashworth Scale. Selective motor control at the ankle was assessed, and observational gait analysis was done. The functional status of the patients was determined by using the gross motor classification system. Botulinum toxin A was injected into the gastrocnemius muscle in all patients, and in four patients with concomitant jump knee gait, a hamstring muscle injection was added. Fourteen patients were included in the study. The mean age was 58.81 +/- 15.34 months. Following injection, spasticity was clinically decreased and statistically significant improvement was noticed in all clinical parameters after 1, 3, and 6 months of injection. The improvement in the clinical parameters decreased after 6 months but not to the baseline. One patient was Level II, four patients were Level III, and six patients were Level IV according to the Gross Motor Function Classification System at baseline. Improvement in the gross motor classification system is continued after 6 months in 12 children. The main goal of spasticity treatment in cerebral palsy is functional improvement. In our study, most of our patients had functional improvement according to the gross motor function classification system and did not change at 6 months.

Walking with modafinil and its use in diplegic cerebral palsy: retrospective review

A retrospective review of pediatric patients with spastic cerebral palsy was undertaken at Texas Tech University Health Sciences Center covering a period from January 1, 2000, until December 31, 2003. One hundred twenty pediatric patients were identified in the Texas Tech University Health Sciences Center child neurology clinic with spastic cerebral palsy. Fifty-nine patients of this group received modafinil treatment for cerebral palsy. Twenty-nine of the 59 patients were noted to have an improving gait on modafinil. Six of these modafinil-treated patients improved from no ambulation or only assisted ambulation to unassisted ambulation. This varied from taking a few steps without holding on to walking down the hall without assistance. Two patients with spastic diplegia secondary to prematurity have had a dramatic improvement in gait during the first 6 months after starting modafinil. Two other patients with spastic diplegia not included in this group of six patients taught themselves to stand up and walk while in water unassisted. During this same time period, only three non-modafinil-treated patients with mild cerebral palsy were noted with gait improvements, but not to the dramatic extent of the modafinil-treated group. A nonambulatory 5-year-old child, who presented for a requested wheelchair prescription because the mother had given up all hope of her child ever walking, is now taking independent steps unassisted after starting modafinil. Modafinil, a central nervous system stimulant, appears to improve tone and ambulation in spastic diplegic cerebral palsy.

Pharmacotherapy of spasticity in children with cerebral palsy

Spasticity is one of the most common symptoms presented by neurologic patients. Apart from surgical management, drug therapy is an important treatment of children suffering from spasticity. In this review, recent advances in the pharmacologic armamentarium are reported in detail. In particular, there are oral medications (benzodiazepines, baclofen, dantrolene sodium, alpha 2 adrenergic agonists) and parenteral medications (botulinum toxin type A and B, alcohol). Moreover, there is also baclofen that can be administered intrathecally. There are some reports supporting the use of intramuscular alcohol (45% and/or 5-7% phenol) to reduce spasticity without the loss of voluntary movement or loss of sensation. Among these drugs, intrathecal baclofen is one of the most effective substances that can reduce spasticity significantly in the upper and lower extremities. Finally, the effectiveness of therapy with botulinum toxin type A in the management of spasticity is analyzed. Botulinum toxin type A reduces hypertonia in the injected muscles for a period of 2 to 4 months without important side effects. The purpose of this article is to provide an overview of available oral and parenteral drugs for treatment of spasticity in cerebral palsy and to outline indications and contraindications.

Physiotherapy assessment and treatment for an ambulant child with cerebral palsy after botox A to the lower limbs: a case report

BACKGROUND AND PURPOSE

Botulinum toxin A is a relatively new, noninvasive treatment option for children with cerebral palsy, providing an effective, short-term intervention to reduce spasticity. It is used as an adjunct to other management including physiotherapy. The purpose of this case report is to evaluate assessment and management by physiotherapy following Botox injections to hamstring and gastrocnemius muscles.

CASE DESCRIPTION

Examination of function and impairment for a 3.5-year-old child with spastic diplegia included the Gross Motor Function Measure, Goal Attainment Scaling, the Physician Rating Scale of gait, dynamic and passive range of movement, and selective motor control. Physiotherapy intervention was play based and occurred at home, at a preschool, and in the therapist's usual clinic setting, twice a week for the first five weeks, then once a week for another five weeks. Intervention consisted of whole and part practice of functional skills using closed and open chain exercises through the full available muscle range.

OUTCOMES

The child showed increased ability in function; however, impairment level results were inconsistent and may not be effective at discerning change in a clinical setting.

DISCUSSION

An increased level of physiotherapy was easily implemented by frequent and clear communication with those directly involved with the child's everyday activities. This is believed to have contributed to the successful outcomes seen.

Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity-dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords 'spasticity', 'child', and 'cerebral palsy', to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time-consuming clinical scoring system.

Flexion contracture after total knee arthroplasty in a patient with Parkinson's disease: successful treatment with botulinum toxin type A

The few reports in the orthopedic literature that discuss outcomes after total knee arthroplasty in patients with Parkinson's disease cite mixed results. These patients are at increased risk for the development of flexion contracture, which has been shown to significantly worsen functional scores. The present report describes the development of a flexion contracture in a patient with Parkinson's disease after total knee arthroplasty. This contracture was successfully treated with manipulation under anesthesia and injections of botulinum toxin type A into the hamstring and gastrocnemius muscles, in conjunction with a static progressive extension orthosis and rigorous physical therapy.

Botulinum toxin for lower limb spasticity in children with cerebral palsy: a single-blinded trial comparing dilution techniques

OBJECTIVE

To compare the effect of equivalent doses of botulinum toxin type A given in high-volume or low-volume injections on lower limb spasticity in children with cerebral palsy.

DESIGN

A total of 17 subjects whose modified Ashworth scale scores in the calf flexors bilaterally ranged from 2 to 3 were enrolled. The right gastrocnemius was injected with botulinum toxin type A using a high-volume preparation (100 IU/4 ml), and the left gastrocnemius was injected with a low-volume preparation (100 IU/1 ml). The amplitude and area of the compound muscle action potential for both medial gastrocnemius muscles, the dynamic muscle range, static muscle range, modified Ashworth scale for both ankles, and the Gross Motor Functional Classification System were assessed before and after treatment.

RESULTS

Spasticity was reduced in both legs. There was no significant difference in the changes in the amplitude and area of compound muscle action potential (P = 0.74 and 0.30, respectively), dynamic muscle range (P = 0.7), static muscle range (P = 0.65), and modified Ashworth scale (P = 1) in the right vs. left legs after botulinum toxin type A injection. The high-volume preparation did not cause more pain.

CONCLUSIONS

A higher volume preparation with a 4-fold dilution of botulinum toxin type A does not yield better results than a low-volume preparation.

Cerebral palsy

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

Intraparotid Injection of Botulinum Toxin A as a Treatment to Control Sialorrhea in Children with Cerebral Palsy

OBJECTIVE

To determine the efficacy of botulinum toxin A in the management of drooling (sialorrhea) in children and young adults with cerebral palsy.

DESIGN

Twenty-one children were enrolled in an open-label, nonblinded prospective study. Subjective and objective measures were used to determine the effect of botulinum toxin A on drooling and saliva production. Subjective measures included visual scales to document the child's severity and frequency of drooling. Objective measures included the number of bibs used per day and salivary secretion. At the initial visit, subjective and objective measures established the child's baseline drooling and saliva production. Fifteen units of botulinum toxin A was injected into each parotid glans. At each fellow-up visit of telephone survey, subjective and objective measures were recorded to monitor the child's drooling and saliva production. A postinjection questionnaire evaluated overall effect and caregiver satisfaction.

RESULTS

The visual analog scales and number of bibs used per day demonstrated statistically significant reduction in severity and frequency of drooling at 2 wks, 1 mo and 2 mos. Salivary production was significantly reduced at 1-mo fellow-up. Eighty-nine percent of the caregivers reported and improvement of their child's drooling after botulinum toxin A injection. Severity-nine percent of caregivers were satisfied with the treatment and would perform the treatment again.

CONCLUSION

Intraparotid injections of botulinum toxin A are efficacious in decreasing severity and frequency of drooling, the number of bibs used per day, and the production of saliva in children with cerebral palsy. The injections are relatively safe and adverse effects were observed in this study.

The use of botulinum toxin in pediatric disorders

Botulinum toxins have an exciting and important role in treating the child with hypertonia. The guidelines presented in this article are those that have been published representing the safe use of botulinum toxins in children. Experience and a decade of research have provided the framework for using botulinum toxins in decreasing deformity and promoting function. In children, a window of opportunity exists with botulinum toxin that allows improved motor control and elongation of shortened muscles. Although 3 to 4 months in an adult life is short, for a child it is a relatively greater proportion of their life experience and may be long enough for skill development. The improvement noted in function after botulinum toxin use is facilitated by comprehensive rehabilitation. The pediatric physiatrist has a unique role in the management of children with cerebral palsy and other conditions with hypertonia. Their knowledge and training reflect an understanding of anatomy and development that allows accurate evaluation of specific functional problems in children related to hypertonia. The pediatric physiatrist has experience in localization of muscles by EMG, nerve stimulation, and surface anatomy. Although many other physicians inject botulinum toxins, goal-directed management is the cornerstone to the physiatrist's thinking and treatment plan. Orthopedic surgery ultimately may be the intervention of choice if persistent contracture or progression of contractures occurs. Working in collaboration with an orthopedist identifies the timing of optimal surgical intervention for alignment. For persistent and severe hypertonia, the treatment team includes a neurosurgeon. All options for spasticity, such as selective posterior rhizotomy and intrathecal baclofen, should be considered. Re-evaluation of the child after selective dorsal rhizotomy or intrathecal baclofen is appropriate and should be discussed with therapists for focal intervention. Communication between members of the team and the family is desirable and frequently is one of the major contributions of the pediatric physiatrist. For children with focal hypertonia, botulinum toxins offer a dramatic but temporary repeatable change that affects rehabilitation. Research rapidly has captured the positive effect of the toxins on impairment and functional limitations. Not to be overlooked are outcomes related to quality of life. The long-term use of botulinum toxins and the role the toxins play throughout the life span of the person with a childhood hypertonic disorder are yet to be determined.

Injectable neuromuscular blockade in the treatment of spasticity and movement disorders

Neuromuscular blockade via injection of alcohol, phenol, or botulinum toxin reduces the tone of overactive muscles in order to restore the appropriate balance between agonists and antagonists. Such a restoration allows improved stretch and increased resting length and can reduce the likelihood of contracture. Alcohol or phenol, injected onto the motor nerve, denatures proteins and promotes axonal degeneration. The onset of action is within hours, whereas the duration of action is variable, ranging from 2 weeks to 6 months and beyond. The advantages of alcohol or phenol chemodenervation lie in their low cost and lack of antigenicity. The disadvantages include the technical difficulty of the injections and significant risk for pain as a result of treatment. Botulinum toxins, purified forms of Clostridium botulinum exotoxins, are injected directly into muscle, where they cleave one or more vesicle fusion proteins, thus blocking release of acetylcholine at the neuromuscular junction. Three commercial products--two of serotype A and one of B--are available. Each differs in its unit potency, side effects, and duration of action. On average, botulinum toxin has a clinical onset of action approximately 12 to 72 hours after injection, with a peak effect at 1 to 3 weeks. Effects then plateau for 1 to 2 months, with patients often requiring reinjection approximately every 3 months. Side effects may include local discomfort at the site of the injection and excessive weakness of the injected or nearby muscles, although more distant effects may occur. Antibody formation is a significant clinical concern and eventually obviates treatment benefit in approximately 5% of patients. Switching serotypes may be effective, at least temporarily. Consensus dosing guidelines have been developed and are presented within. Numerous studies have suggested that botulinum toxin has a role in the care of children with spasticity or dystonia related to cerebral palsy, and may improve equinus, gait, upper extremity use, comfort, and care. Evidence of functional improvement remains equivocal in the severely impaired child; however, there is evidence for improvement in less impaired children. The optimal candidate for injectable neuromuscular blockade is one who has a limited number of muscles that need treatment, who does not have fixed contracture, and who retains selective motor control. The ultimate goal of treatment for the hypertonic child is to maximize function, comfort, and independence. Hypertonia is only one aspect of the upper motoneuron syndrome, which includes both positive and negative symptoms. The treatment program, in which chemodenervation is only one tool, requires a multidisciplinary evaluation and individualized plan to address the whole patient.

[Botulinum toxin type A in children: evaluation of indications with a review of the literature]

INTRODUCTION

The aim of this study is to review the literature to indications of botulinum toxin type A in children.

METHOD

We review the international literature from 1990 to 2002 by querying the Pubmed database with the keywords "children" and "botulinum toxin".

RESULTS

Two hundred and forty-eight articles are retrieved. We selected the most relevant 64 articles among them. Several questions remain pending: which optimal dose, which periodicity for injections, which optimal age to prolong efficiency? The main criteria to estimate efficiency is functional ability improvement. No significant side effects are noted. The main use of botulinum toxin is the management of the spastic lower limb in cerebral palsy.

DISCUSSION

This review of the literature makes it possible to specify the interests and the operational limits of botulinum toxin in the child. Its effectiveness with the upper limb is not proven. The other indications remain to be studied in a more precise way.

CONCLUSION

This review shows many studies give the indications of botulinum toxin in children. The main indication is the lower limb spaticity in cerebral palsy. New prospective and double-blind studies should be performed with larger samples.

Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin

Botulinum A toxin produces selective and reversible chemodenervation that can be employed to balance muscle forces across joints in children with cerebral palsy (CP). Currently, there are two commercially available botulinum A toxin formulations (BOTOX) and Dysport). The amount of botulinum A toxin required depends upon the number of muscles that are targeted, and the size of the patient. In order to achieve adequate chemodenervation with botulinum A toxin, the following conditions must be met: (i) a sufficient number of units of toxin must be injected in order to neutralize neuromuscular junction (NMJ) activity; (ii) an appropriate drug volume is required in order to optimize the delivery of the toxin to the NMJs; and (iii) localization of the injecting needle through the fascia of the target muscle is necessary. Localization of the injection may be facilitated by active electromyography, ultrasonography, palpation of the muscle belly, and/or use of anatomic landmarks. Botulinum A toxin injections are indicated for use in pediatric patients with CP to: (i) improve motor function by balancing muscle forces across joints; (ii) improve health-related quality of life by decreasing spasticity and/or decreasing caregiver burden; (iii) decrease pain from spasticity; (iv) enhance self-esteem by diminishing inappropriate motor responses; and (v) provide a presurgical diagnostic tool. Following intramuscular injections of botulinum A toxin, short-term benefits of reduced spasticity are observed in approximately 70-82% of children. The intermediate term (1-2 years) efficacy rate is approximately 50%. The most common deformity treated with toxin injections in pediatric patients with CP is equinus foot deformity. However, efficacy of toxin injections for the management of crouched gait, pelvic flexion contracture, cervical spasticity, seating difficulties, and upper extremity deformity also has been documented. In addition, toxin injections have been shown to manage painful muscle spasticity associated with surgery or application of casts and painful cervical spasticity with or without dystonia. Toxin injections can also be used as a diagnostic tool to determine the appropriateness of other interventions by observing the muscle response to the injection in order to gain additional information for the development of a treatment plan. Botulinum A toxin, when used in appropriate doses, is well tolerated.

Treatment of spasticity with botulinum toxin

Spasticity is an abnormal increase in muscle contraction often caused by damage to central motor pathways that control voluntary movement. During clinical examination, spasticity manifests as an increase in stretch reflexes, producing tendon jerks and resistance appearing as muscle tone. There are many causes of spasticity, including demyelination from multiple sclerosis, congenital damage from diseases such as cerebral palsy, trauma to the brain or spinal cord, hemorrhage or infarction, and other pathologic conditions that interrupt neural pathways. Effects of spasticity range from mild muscle stiffness to severe, painful muscle contractures and repetitive spasms that reduce mobility and substantially impede normal activities of daily living. Botulinum toxin therapy reduces spasticity and pain associated with several disorders. Local treatment with botulinum toxins can be used as adjunctive therapy, along with oral antispasticity medications, or alone to provide localized decrease in symptoms of spasticity and pain. Botulinum toxin therapy may be particularly useful for patients with spasticity due to stroke, whose treatment can be tailored based on recovery of function over time. In addition, botulinum toxin therapy is safe for pediatric patients, including children with cerebral palsy, who may not be able to tolerate the cognitive side effects of oral medications. Results of studies evaluating botulinum toxin for the treatment of spasticity due to various causes are presented here.

Change of dynamic gastrocnemius and soleus muscle length after block of spastic calf muscle in cerebral palsy

OBJECTIVE

The purpose of this study was to evaluate the efficacy of gastrocnemius and soleus muscle length measured by gait analysis for characterizing the spastic calf muscles in ambulant cerebral palsy.

METHODS

A total of 20 limbs in the 16 children with diplegic or hemiplegic cerebral palsy showing spasticity of the calf muscle were analyzed by three-dimensional gait analysis before and after botulinum toxin injection. RESULTS; The mean maximal ankle dorsiflexion angle, the minimal knee flexion angle in stance, and the dynamic gastrocnemius and soleus muscle lengths increased after the block. Paradoxically the dynamic gastrocnemius muscle lengths decreased in the eight patients after the block, all of whom had a common characteristic of the genu recurvatum. In contrast, dynamic soleus length, knee angle, and ankle angle improved after the injection.

CONCLUSION

Gastrocnemius length and soleus length are useful variables to evaluate the antispastic effect of botulinum toxin in patients with cerebral palsy. When the genu recurvatum is present, the soleus muscle length is more informative than gastrocnemius length.

Effect of botulinum toxin on endplate noise in myofascial trigger spots of rabbit skeletal muscle

OBJECTIVE

To assess the effect of botulinum toxin type A (BTX-A) on the endplate noise prevalence in rabbit myofascial trigger spots to confirm the role of excessive acetylcholine release on the pathogenesis of myofascial trigger points and to develop an objective indicator of the effectiveness of BTX-A in the treatment of myofascial trigger points.

DESIGN

Eighteen adult New Zealand rabbits were divided into three groups that received a single bolus of BTX-A over a myofascial trigger spot region on one side of the biceps femoris muscle. Another 10 rabbits received multiple-point injections in a myofascial trigger spot where endplate noises were found. A control study was performed on the other side of the biceps femoris muscle. The endplate noise prevalence in a myofascial trigger spot region was assessed.

RESULTS

It was found that injection of BTX-A reduced the prevalence of endplate noise. No significant differences between a single bolus injection and multiple-point injections were noted, although there was some evidence that multiple-point injections might maintain the endplate noise decreasing effect much longer than a single injection.

CONCLUSIONS

This study demonstrated the suppressive effect of BTX-A on endplate noise prevalence in a myofascial trigger spot region. The prevalence of endplate noise in the myofascial trigger point region may be a useful objective indicator for evaluating the therapeutic effectiveness of BTX-A injection to treat myofascial trigger points.

Effect of intramuscular botulinum toxin injection on upper limb spasticity in stroke patients

OBJECTIVE

To evaluate the therapeutic effect of intramuscular injection of botulinum toxin on spasticity of the upper limb, with emphasis on its influence over limb function.

DESIGN

An open-label, noncontrolled trial with a duration of 12 wk was designed to determine the safety and efficacy of intramuscular botulinum toxin A injection in the treatment of 16 patients with stroke with spastic hemiparesis. Electromyographically guided intramuscular botulinum toxin A injections were applied to the spastic limbs. A detailed scale system was used for the evaluation of muscle tone and functional changes induced by botulinum toxin A treatment.

RESULTS

No major side effect secondary to botulinum toxin A injection was reported. Statistically significant (P < 0.05) improvements of muscle tone, joint range of motion, hand muscle strength, and muscular pain were seen after the injection. The improvements lasted up to 8-12 wk after the treatment. However, there was no significant functional improvement except in two of the patients.

CONCLUSIONS

Botulinum toxin A injection may help relieve upper limb spasticity and pain in patients with stroke. Its effect on function is probably determined by case selection.

Parameters for predicting favorable responses to botulinum toxin in children with cerebral palsy

We sought markers for predicting a favorable outcome of botulinum toxin A injected to the lower-extremity muscles of 26 children with hemiplegic or diplegic cerebral palsy. Clinical assessment preceding and 1 month following injection included gross motor function measure, a modified Ashworth scale, and evaluation of range of motion of knee extension and ankle dorsiflexion. Response to treatment was classified based on a parent questionnaire. The 19 children (73%) considered by their parents as being good responders were compared to the 7 (27%) considered as being poor responders. In the good responders, the preinjection Ashworth scale (spasticity) was significantly higher (P < .05) and gross motor function measure scores (function) were lower (P < .05). Sixty-eight percent of the good responders were nonindependent walkers compared to 14% of the poor responders (P < .05). There were no differences in age, type of cerebral palsy, and dose of injection. An Ashworth scale indicating increased muscle tone, lower gross motor function measure scores, and nonindependent ambulatory status were predictive for a favorable response to botulinum toxin A injections and can guide patient selection and expectations of treatment outcome.

Open-label study of botulinum toxin for upper limb spasticity in cerebral palsy

The objective of this study was to assess the efficacy of botulinum toxin for upper limb spasticity in cerebral palsy. An open-label study was conducted in 11 children with cerebral palsy. Post-botulinum toxin assessment was conducted in weeks 1, 4, and 16, with averaged scores being analyzed. The Clinical Global Impression Scale of the mothers showed marked, moderate, and mild improvement in five, four, and two cases, respectively. The Modified Ashworth Spasticity Scale score showed a statistically significant decrease in the mean spasticity score (P < .003). Other tests were performed depending on the cognition of the child. Increase in joint motion occurred in all five children assessed using web space (P = .043). For the Jebson Hand Function Test, improvement occurred in all five cases assessed (P < .03). Four of five (80%) children could perform tasks that they failed before they were given botulinum toxin. Botulinum toxin is useful in decreasing spasticity and improving the upper limb function of young children with cerebral palsy with normal cognition. Motivated families should be selected with a specific target of using botulinum toxin as an adjunct in a habilitation program.

Impairment, disability, and satisfaction outcomes after lower-extremity botulinum toxin a injections for children with cerebral palsy

PURPOSE

The purpose of this study was to document impairment, disability, and parent satisfaction outcomes for children with cerebral palsy who received botulinum toxin A (BtA) injections.

METHODS

Seven children, three to 11 years old, participated in this multiple single-subject AB design study. Impairment, disability, and satisfaction outcomes were documented using passive range of motion measurements, Modified Ashworth Scale scores, and the Canadian Occupational Performance Measure. These outcomes were measured every two weeks during the two-month baseline phase and the four-month intervention phase. Outcomes for each child were graphed and visually analyzed for changes in level, trend, and slope.

RESULTS

After BtA injections, all children demonstrated an increase in passive range of motion and a decrease in spasticity in at least some of the injected muscles. Six of the seven children demonstrated improvements in disability and parent satisfaction outcomes.

CONCLUSIONS

Improvement in a variety of outcomes may be observed after BtA injections in children with cerebral palsy and lower-extremity spasticity who are ambulatory.

Current evidence for the use of botulinum toxin type A in the management of children with cerebral palsy: a systematic review

Management of children with cerebral palsy (CP) is the focus of considerable resources in many countries, so that evaluation of the efficacy for new and established treatments is imperative. Botulinum toxin type A (BTX-A) is a relatively new method of spasticity management in children with cerebral palsy. It has been the focus of extensive research since its application to cerebral palsy 10 years ago. In a systematic review relating to the management of the lower limb in cerebral palsy 156 papers were identified. These were categorized according to Sackett and the World Health Organisation International Classification of Impairments, Disabilities and Handicaps model. We identified 10 randomized trials evaluating the use of BTX-A in the lower limb in children with cerebral palsy in a systematic review. A meta-analysis showed the pooled risk difference between BTX-A and placebo in three trials was 0.25 (95% CI 0.13, 0.37) and 0.23 (95% CI -0.06, 0.53) for two trials of BTX-A and casting using the physicians rating scale. These represent moderate treatment effects that are dosage-dependent. Outcomes were also compared for function in five studies. The type of evidence for BTX-A was graded by each treatment indication and directions for future research were then drawn from the available evidence.

Botulinum toxin type a neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial

BACKGROUND

Focal spasticity of the gastrocnemius-soleus muscles causes equinus gait in children with cerebral palsy (CP). Botulinum toxin type A (BTX-A), a neuromuscular blocking agent, reduces muscle tone/overactivity in dystonia, stroke, and CP.

OBJECTIVE

A prospective, open-label, multicenter clinical trial evaluated the long-term safety and efficacy of repeated intramuscular injections of BTX-A on equinus gait in CP children.

METHODS

Nine centers enrolled 207 children. BTX-A injections (4 U/Kg) were given approximately every 3 months (maximum dose 200 U per treatment). Outcome measures included a Physician Rating Scale of gait, ankle range of motion measurements, and the incidence and profile of adverse events.

RESULTS

One hundred fifty-five (75%) of 207 children completed at least 1 year with a total of 302 patient years of BTX-A treatment. The mean duration of BTX-A exposure was 1.46 years per patient. Dynamic gait pattern on the Physician Rating Scale improved in 46% of patients (86/185) at first follow-up. The response was maintained in 41% to 58% of patients for 2 years. Both gait pattern and ankle position improved at every visit. The most common treatment-related adverse events included increased stumbling, leg cramps, leg weakness, and calf atrophy in 1% to 11% of patients. No treatment-related serious adverse events were reported. Only 6% (7/117) of patients with pre- and postantibody samples had both detectable antibodies and a subsequent treatment failure.

CONCLUSION

BTX-A proved both safe and effective in the chronic management of focal muscle spasticity in children with equinus gait.

The effect of botulinum toxin type A on the functional ability of the child with spastic hemiplegia a randomized controlled trial

It has been demonstrated that botulinum toxin type A (BTX-A) injections reduce spasticity and improve muscle growth in children with spasticity. It has been postulated that BTX-A allows the learning of more normal movement patterns. The aim of this study was to measure the effect of this treatment on functional ability, as measured by the Gross Motor Function Measure (GMFM), in children with spastic hemiplegic cerebral palsy. Children of 3--13 years and meeting the selection criteria were randomly allocated to the control or injection group using a matched pair design. A match constituted a child within 6 months of age with the same Modified Ashworth Score (MAS) for the gastroc-soleus and within 10% of the same goal scores on the Gross Motor Function Measure. Twelve matched pairs were enrolled. Outcomes were measured on enrolment and at 1, 3 and 6 months post injection. The time course of the response to BTX-A was assessed with measurements of the MAS, dynamic range of motion (R1) and static muscle length (R2). Motor function was assessed using the 88-item GMFM and parental satisfaction with a 10-point visual analogue scale. Within pair comparisons of the GMFM using the Wilcoxon signed rank test indicated that the treatment group made significantly greater gains than controls at 3 months (P=0.02) with even greater differences seen at 6 months (P=0.004). Using parametric statistics, the intrapair difference in proportional change of GMFM increased from 35% (4 to 65) at 3 months to 52% (17--87) at 6 months. Response to injection was confirmed by a decrease in MAS in the treatment group and very little change in controls. This difference was significant (P=0.002) at 3 months and was attenuated but still significant (P=0.016) at 6 months; the difference in proportional change decreased from 44% at 3 months to 22% at 6 months. Changes in R1 reflected those of MAS in the treatment group and deteriorated significantly over the study period in controls. Parents of children in the treatment group were more satisfied than controls, but satisfaction scores did not correlate with changes in function or technical outcomes suggesting that this may be a placebo effect. The changes in GMFM correlated with changes in technical outcomes at 3 months, suggesting a causal relationship. The intrapair differences in GMFM continued to increase even after the local response to injection had started to wane.

Use of botulinum toxin type A in pediatric patients with cerebral palsy: a three-center retrospective chart review

Over the last several years, botulinum toxin type A has gained widespread use for the management of focal spasticity in children with cerebral palsy. To assess the current patterns of botulinum toxin type A use in the clinical setting, the dose, muscles injected, age at injection, and interval between injections of botulinum toxin type A treatments were examined in a retrospective chart review of children with cerebral palsy (N = 270) over a 2-year period at three major treatment centers. The average dose of botulinum toxin type A across the three centers ranged from 7.7 to 10.8 U/kg body weight, and the average total amount of botulinum toxin type A injected at a single visit ranged from 154 to 205 U. The majority of botulinum toxin type A injections were to the muscles to the lower limbs. The average age at first injection was 6.2 years, and the average interval between injections ranged from 134 to 199 days.

Spasticity management: an overview

Recent developments in therapeutic interventions for children with spasticity have complicated managerial decision making. A simplified paradigm for the pathophysiology of spasticity is presented, which emphasizes the ways in which treatment modalities disrupt hyperexcitable segmental spinal reflex arcs. Various techniques for the management of spasticity are reviewed, along with factors relevant to proper patient selection for therapeutic intervention. Potential goals for spasticity management are considered as are outcome measures for assessing the efficacy of these technologies.

Randomised double blind placebo controlled trial of the effect of botulinum toxin on walking in cerebral palsy

BACKGROUND

Cerebral palsy is the commonest cause of severe physical disability in childhood. For many years treatment has centred on the use of physiotherapy and orthotics to overcome the problems of leg spasticity, which interferes with walking and can lead to limb deformity. Intramuscular botulinum toxin (BT-A) offers a targeted form of therapy to reduce spasticity in specific muscle groups.

AIMS

To determine whether intramuscular BT-A can improve walking in children with cerebral palsy.

DESIGN

Randomised, double blind, placebo controlled trial.

METHODS

Forty patients with spastic diplegia or hemiplegia were enrolled. Twenty two received botulinum toxin and 18 received placebo. The primary outcome measure was video gait analysis and secondary outcome measures were gross motor function measure (GMFM), physiological cost index (PCI), and passive ankle dorsiflexion.

RESULTS

Video gait analysis showed clinically and statistically significant improvement in initial foot contact following BT-A at six weeks and 12 weeks compared to placebo. Forty eight per cent of BT-A treated children showed clinical improvement in VGA compared to 17% of placebo treated children. The GMFM (walking dimension) showed a statistically significant improvement in favour of the botulinum toxin treated group. Changes in PCI and passive ankle dorsiflexion were not statistically significant.

CONCLUSION

The study gives further support to the use of intramuscular botulinum toxin type A as an adjunct to conventional physiotherapy and orthoses to reduce spasticity and improve functional mobility in children with spastic diplegic or hemiplegic cerebral palsy.

Motor control testing of upper limb function after botulinum toxin injection: a case study

OBJECTIVE

To evaluate changes in upper extremity function in a hemiparetic patient after treatment with botulinum toxin (BTX) using motor-control testing (MCT) techniques.

DESIGN

Interventional with longitudinal study, open label.

SETTING

A children's hospital and a motor-control laboratory at a major academic center.

PARTICIPANTS

A 16-year-old male with right hemiparetic cerebral palsy and a healthy 12-year-old control subject.

INTERVENTIONS

BTX injections to the elbow and wrist flexors.

MAIN OUTCOME MEASURES

MCT was used to examine 4 upper extremity movements: forward reach, bilateral rhythmic movements (both muscle homologous and direction homologous), isometric pinch, and hand tapping. The patient was tested before treatment and at 2, 4, 6, 12, 18, and 24 weeks after treatment. In addition, range of motion (ROM), the Ashworth scale of spasticity, Functional Independence Measure, and the mobility and activities of daily living (ADL) sections of the Pediatric Evaluation of the Disability Inventory were performed.

RESULTS

Forward reach demonstrated little change initially despite patient reports of "feeling looser." Improvement was noted after 18 weeks, but returned to baseline level at 24 weeks. Bilateral rhythmic movements also showed slight improvement at 18 weeks. Pinch force increased significantly after 2 weeks, but declined again at 6 weeks. Improvements occurred in ROM and the Ashworth rating of spasticity, but were not temporally associated with each other or with MCT results. Functional assessment data did not change during the study period.

CONCLUSIONS

Improvements in more complex motor tasks were noted after significant delay from the time of treatment, while simpler tasks demonstrated a more rapid improvement, followed by a rapid return to baseline levels. This case suggests that MCT techniques can provide quantitative and qualitative data, which can add new information about upper extremity motor disability and the outcome of treatment.

Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group

Increased gastrocnemius/soleus muscle tone in children with cerebral palsy may cause an equinus of the ankle. Botulinum toxin type A (BTX), a neuromuscular blocking agent, reduces muscle tone in various neuromuscular disorders. The safety and short-term efficacy of BTX injections were evaluated in a prospective, 3-month, double-blind, randomized clinical trial involving 114 children with cerebral palsy and dynamic equinus foot deformity. Outcome was determined by observational gait analysis, ankle range-of-motion measurements, and quantification of muscle denervation by nerve conduction. Patients in the BTX group demonstrated improved gait function and partial denervation of the injected muscle. No serious adverse events were reported.

Effects of botulinum toxin A on upper limb spasticity in children with cerebral palsy

OBJECTIVE

Botulinum toxin A inhibits presynaptic release of acetylcholine at the neuromuscular junction and has reportedly been successful in the treatment of spastic disorders. This prospective study attempted to determine whether botulinum toxin A injection resulted in clinically measurable gains for 4 mo.

DESIGN

Measurements were obtained from 32 children (range, 1-18 yr; average age, 6.9 yr) with hemiplegic or quadriplegic cerebral palsy before and at 1, 3, and 4 mo after botulinum toxin A injections. Spasticity was measured using the Modified Ashworth Scale for 12 different joints.

RESULTS

Results showed that spasticity as measured by Ashworth scores for elbow and wrist extension clearly declined (P < 0.02) by 1 mo after botulinum toxin A injection, and diminished spasticity continued for 3-4 mo. Caregivers reported improvement in subjectively rated management, appearance, and function. However, patient response to botulinum toxin A injection was not predictable. Age had no significant relationship to gains.

CONCLUSIONS

Further research is needed on the use of botulinum toxin A to diminish spasticity and improve function.