Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

Botox Injections in Paraspinal Muscles Result in Low Maximal Specific Force and Shortening Velocity in Fast but Not Slow Skinned Muscle Fibers

STUDY DESIGN

Basic science, experimental animal study.

OBJECTIVE

To determine the effects of Botulinum toxin type A (BTX-A) injections on the mechanical properties of skinned muscle fibers (cells) of rabbit paraspinal muscles.

SUMMARY OF BACKGROUND DATA

BTX-A has been widely used in the treatment of disorders of muscle hyperactivity, such as spasticity, dystonia, and back pain. However, BTX-A injection has been shown to cause muscle atrophy, fat infiltration, and decreased force output in target muscles, but its potential effects on the contractile machinery and force production on the cellular level remain unknown.

METHODS

Nineteen-month-old, male New Zealand White Rabbits received either saline or BTX-A injections into the paraspinal muscles, equally distributed along the left and right sides of the spine at T12, L1, and L2 at 0, 8, 12, 16, 20, and 24 weeks. Magnetic resonance imaging was used to quantify muscle crosssectional area and structural changes before and at 28 weeks following the initial injection. Skinned fibers isolated from the paraspinal muscles were tested for their active and passive force-length relationships, unloaded shortening velocity, and myosin heavy chain isoforms.

RESULTS

BTX-A injections led to significant fat infiltration within the injected muscles and a greater proportion of IIa to IIx fibers. Isolated fast fibers from BTX-A injected animals had lower active force and unloaded shortening velocity compared with fibers from saline-injected control animals. Force and velocity properties were not different between groups for the slow fibers.

CONCLUSION

Injection of BTX-A into the paraspinal rabbit muscles leads to significant alterations in the contractile properties of fast, but not slow, fibers.Level of Evidence: N/A.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Pain Management in Athletes With Impairment: A Narrative Review of Management Strategies

OBJECTIVE

To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population.

DATA SOURCES

A comprehensive literature search was performed linking pain with terms related to different impairment types.

MAIN RESULTS

There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete.

CONCLUSIONS

It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.

Effect of load carriage on chronic low back pain in adults with cerebral palsy

BACKGROUND

Chronic low back pain (LBP) is a common secondary musculoskeletal problem among adults with cerebral palsy (CP). This study investigated the feasibility of incorporating backpack carriage with daily production activities for relieving chronic LBP among adults with CP.

OBJECTIVES

The effects of backpack carriage in relieving chronic LBP for adults with CP.

STUDY DESIGN

A multiple bivariate approach with convenience sampling.

METHODS

Nine adults with CP suffering from chronic LBP were scheduled to carry a 4 lb backpack at work for 60 minutes on weekdays for four consecutive weeks. The pain level was rated by the participants on an 11-point scale. Muscle activity of erector spinae was measured by surface electromyography.

RESULTS

Significant improvement in back pain was found immediately after the backpack carriage with no adverse effect reported. It was accompanied with significantly reduced erector spinae activity. Although the overall change in pain ratings across the study period was not significant, a decreasing trend with time was observed.

CONCLUSIONS

The loaded backpack has the potential to serve as an 'orthosis' for immediate back pain relief among adults with CP. Its underlying mechanism can be attributed to a reduction in back muscle tension during the load carriage.

The adult with cerebral palsy

Advances in medical and surgical care over the past 20 years have resulted in children who formerly would have died at birth or infancy now surviving well into adulthood, many with permanent physical disabilities, including those caused by cerebral palsy. Inadequate medical and surgical diagnoses and intervention are prevalent in the adult cerebral palsy population. Decreased physical activity and participation in physical therapy and fitness programs, along with loss of strength, contractures, and pain are common factors in the loss of functional weight bearing, self-care, and daily performance over time. Increased awareness of these problems is needed by adult health care providers who provide care to these individuals and also by pediatric providers who may be able to intervene and prevent some of the long-term problems. Early identification and intervention in the child and younger adult remain the ideal in the pursuit of optimal musculoskeletal function and lifestyle throughout the adult years.

Cerebral palsy lifetime care - four musculoskeletal conditions

Cerebral palsy (CP) has always been considered a static condition in the neurological sense. Secondary and associated conditions that occur in the patient with CPcan progress over time and cause unwanted sequelae. This paper discusses four musculoskeletal conditions that present across the lifetime and can lead to progressive loss of function in the patient with CP. Patella alta can be particularly painful in the early adult years, limiting mobility particularly when associated with crouch gait. Adults with lower-extremity weight-bearing status having hip dysplasia, progressive over time, often develop pain and severe degenerative arthritis, with or without arthrodesis. Spondylolysis, particularly at the L5 S1 level, is fairly common in the ambulatory adult with diplegia and may, if not diagnosed early, progress to spondylolisthesis. Cervical stenosis appears to be more prevalent in adults with spastic quadriparesis and dystonia and is often associated with myelomalacia and/or radiculopathy. All four of these conditions may be lessened, or even prevented, with intervention and diagnosis in the younger years. Possible interventions and outcomes over time are discussed in the context of multidisciplinary team management of the individual with CP.

The psoas muscle as cause of low back pain in infantile cerebral palsy

Psoas muscle spasticity is hypothesised as a rare cause of low back pain in patients with infantile cerebral palsy. The authors describe a new manoeuvre for the study of psoas tenderness and ultrasound (US)-guided transabdominal botulinum toxin injection technique. A possible causal relationship between psoas tension and low back pain was found incidentally in two examined cases. In subsequent patients, botulinum toxin was injected and, in cases of disappearance of symptoms, the psoas tendon was sectioned at the pelvic brim with definitive disappearance of pain. The relationship between psoas tension and low back pain in patients with infantile cerebral palsy seems likely, given the result in the four patients.

La douleur chez le sujet adulte infirme moteur cérébral

INTRODUCTION

Pain is the main problem in patients with cerebral palsy. To improve the quality of life of people with cerebral palsy, a good knowledge of the clinical syndrome is necessary.

METHOD

We reviewed the published data of the APIB study. We analysed data about pain, especially its correlation with age, motor handicap, and depressive syndrome. We also reviewed the literature to survey the pain syndrome in such a situation.

RESULTS

A total of 562 patients responded to the APIB survey (mean age 36+/-14 years). Of these, 75% complained about physical pain. Pain was significantly associated with age, motor handicap, depressive syndrome, and sleep disorders.

DISCUSSION

A study of the literature confirms our results on pain in cerebral palsy from the APIB survey. The main localisations of pain are the spine, and scapular and pelvic girdles. Pain syndromes of the upper and lower limbs are also frequent, with much due to overuse. Some rare causes include heterotopic ossifications.

CONCLUSION

A good knowledge of the characteristics of the pain syndromes in people with cerebral palsy is important because of the great prevalence of this problem in this population. Better knowledge will help prevent the pain and improve quality of life.