1
|
Saranti A, Dragoumi P, Papavasiliou A, Zafeiriou D. Current approach to cerebral palsy. Eur J Paediatr Neurol 2024; 51:49-57. [PMID: 38824721 DOI: 10.1016/j.ejpn.2024.05.015] [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] [Received: 02/23/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
This teaching review aims to provide an overview of the current approach to children with cerebral palsy (CP), retrieving the best available evidence and summarizing existing knowledge in the field of CP in children. We also highlight areas where more research is needed and novel strategies for diagnosing and treating cerebral palsy. CP includes a group of permanent disorders of movement and posture that cause activity limitation. Multiple risk factors, occurring preconceptionally, prenatally, perinatally, or postneonatally, are involved in the pathogenesis of CP, with the prenatal ones accounting for 80-90 % of cases. Due to its heterogeneity, CP has various classifications, but usually is classified based on clinical findings and motor impairment. Standardized function classification systems have been developed to address inconsistencies in previous classifications. The combination of clinical assessment and validated predictive tools is recommended for an early diagnosis, which is important for early intervention and prevention of secondary impairments. The therapeutic regimen in CP involves prevention and management of the motor and associated problems. It includes the enhancement of motor performance, the enrichment of cognition and communication skills, the prevention of secondary impairments, and the support of parents and caregivers. The care of CP children demands a multidisciplinary approach focused on improving motor skills, reducing comorbidities, enhancing the quality of life, and prolonging survival.
Collapse
Affiliation(s)
- Anna Saranti
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | | | - Dimitrios Zafeiriou
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece.
| |
Collapse
|
2
|
Sæther R, Elvrum AKG, Brændvik SM. Correspondence between Expected, Perceived, and Measured Effects of BoNT-A Treatment in Calf Muscles among Children and Adolescents with Cerebral Palsy: A Mixed Methods Study. J Clin Med 2024; 13:1453. [PMID: 38592286 PMCID: PMC10933865 DOI: 10.3390/jcm13051453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/13/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Our study explores the relationship between expected, perceived, and measured effects of botulinum toxin A (BoNT-A) treatment and saline (placebo) in children and adolescents with cerebral palsy (CP) in the calf muscles of 20 children and adolescents with cerebral palsy (CP), aged 4-15 years, using the Gross Motor Function Classification System (GMFCS) I-II. (2) Methods: A mixed methods parallel database design was used. Quantitative and qualitative data were collected at baseline and four weeks after treatment. The primary quantitative measure was gross energy cost (EC) during walking, obtained from a 5-Minute Walk Test (5MWT), while qualitative semi-structured interviews were performed with each parent and child/adolescent individually. (3) Results: Four weeks after treatment, we did not find any correspondence between expected, measured, and perceived effects. Interestingly, parental perceptions of treatment effects were more consistent than the measured outcomes. We also observed a connection between parental treatment expectations and perceived effects, often related to reduced energy expenditure. Children tended to view their parents as treatment experts and had fewer expectations and perceptions themselves. (4) Conclusions: These findings support the importance of child-centered care, which entails actively listening to children's expectations and perceptions during the treatment process.
Collapse
Affiliation(s)
- Rannei Sæther
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, 7130 Trondheim, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet—Oslo Metropolitan University, P.O. Box 4, St. Olavsplass, 0130 Oslo, Norway
| | - Ann-Kristin Gunnes Elvrum
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, 7130 Trondheim, Norway; (A.-K.G.E.); (S.M.B.)
- Clinic of Rehabilitation, St. Olav’s Hospital, Trondheim University Hospital, 7130 Trondheim, Norway
| | - Siri Merete Brændvik
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, 7130 Trondheim, Norway; (A.-K.G.E.); (S.M.B.)
- Clinic of Rehabilitation, St. Olav’s Hospital, Trondheim University Hospital, 7130 Trondheim, Norway
| |
Collapse
|
3
|
Towards functional improvement of motor disorders associated with cerebral palsy. Lancet Neurol 2023; 22:229-243. [PMID: 36657477 DOI: 10.1016/s1474-4422(23)00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
Cerebral palsy is a lifelong neurodevelopmental condition arising from non-progressive disorders occurring in the fetal or infant brain. Cerebral palsy has long been categorised into discrete motor types based on the predominance of spasticity, dyskinesia, or ataxia. However, these motor disorders, muscle weakness, hypotonia, and impaired selective movements should also be discriminated across the range of presentations and along the lifespan. Although cerebral palsy is permanent, function changes across the lifespan, indicating the importance of interventions to improve outcomes in motor disorders associated with the condition. Mounting evidence exists for the inclusion of several interventions, including active surveillance, adapted physical activity, and nutrition, to prevent secondary and tertiary complications. Avenues for future research include the development of evidence-based recommendations, low-cost and high-quality alternatives to existing therapies to ensure universal access, standardised cerebral palsy registers to harmonise epidemiological and clinical information, improved adult screening and check-up programmes to facilitate positive lived experiences, and phase 3 trials for new interventions.
Collapse
|
4
|
Li J, He L, Tang H, Peng T, Long Y, Zeng P, Huang Y, Chen Z, Han M, Xu K. Adverse events after different forms of botulinum neurotoxin A injections in children with cerebral palsy: An 8-year retrospective study. Dev Med Child Neurol 2023; 65:86-93. [PMID: 35674175 DOI: 10.1111/dmcn.15305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 01/28/2023]
Abstract
AIM To compare the risks of adverse events 3 months after Onabotulinumtoxin-A and Lanbotulinumtoxin-A injections in children with cerebral palsy (CP) and to identify risk factors and associations. METHOD A total of 1037 children (682 males, 355 females; mean age 5 years 2 months [SD 3 years]; age range 2 years-17 years 10 months) with CP underwent 1013 Onabotulinumtoxin-A injections and 418 Lanbotulinumtoxin-A injections from 2012 to 2021. Information was recorded in a purpose-built database. RESULTS The adverse event rates of Onabotulinumtoxin-A and Lanbotulinumtoxin-A were reported as 13.92% and 11.96% respectively. Most adverse events were mild and self-limiting. Children in Gross Motor Function Classification System (GMFCS) levels IV to V had a higher risk of adverse events than those in GMFCS levels I to III (odds ratio [OR] [95% confidence interval {CI}] = 3.65 [1.56, 5.40], p < 0.01). The history of recent illness and higher dose increased the likelihood of adverse events (OR [95% CI] = 2.00 [1.55, 3.00] and 2.20 [1.53, 3.07] respectively, p < 0.01). Sex, age, and the number of injections had no significant effect on adverse event rates (p > 0.05). The incidence of upper respiratory tract infection and lower respiratory tract infection after injections was weakly correlated with the incidence before injections (r = 0.36 and r = 0.27 respectively, p < 0.01). INTERPRETATION Occurrence of adverse events was similar between Onabotulinumtoxin-A and Lanbotulinumtoxin-A in children with CP. Dose, GMFCS level, and health background were risk factors. WHAT THIS PAPER ADDS The prevalence of adverse events was similar between Onabotulinumtoxin-A and Lanbotulinumtoxin-A in children with cerebral palsy (CP). The prevalence of adverse events increased with the severity of CP and the injected dose. Sex, age, and number of injections had no significant effect on the prevalence of adverse events.
Collapse
Affiliation(s)
- Jinling Li
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Lu He
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Hongmei Tang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Tingting Peng
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Yao Long
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Peishan Zeng
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Yuan Huang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Zhaofang Chen
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Mingshan Han
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| | - Kaishou Xu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou
| |
Collapse
|
5
|
Botulinum Toxin Intervention in Cerebral Palsy-Induced Spasticity Management: Projected and Contradictory Effects on Skeletal Muscles. Toxins (Basel) 2022; 14:toxins14110772. [PMID: 36356022 PMCID: PMC9692445 DOI: 10.3390/toxins14110772] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Spasticity, following the neurological disorder of cerebral palsy (CP), describes a pathological condition, the central feature of which is involuntary and prolonged muscle contraction. The persistent resistance of spastic muscles to stretching is often followed by structural and mechanical changes in musculature. This leads to functional limitations at the respective joint. Focal injection of botulinum toxin type-A (BTX-A) is effectively used to manage spasticity and improve the quality of life of the patients. By blocking acetylcholine release at the neuromuscular junction and causing temporary muscle paralysis, BTX-A aims to reduce spasticity and hereby improve joint function. However, recent studies have indicated some contradictory effects such as increased muscle stiffness or a narrower range of active force production. The potential of these toxin- and atrophy-related alterations in worsening the condition of spastic muscles that are already subjected to changes should be further investigated and quantified. By focusing on the effects of BTX-A on muscle biomechanics and overall function in children with CP, this review deals with which of these goals have been achieved and to what extent, and what can await us in the future.
Collapse
|
6
|
Sheu J, Cohen D, Sousa T, Pham KLD. Cerebral Palsy: Current Concepts and Practices in Musculoskeletal Care. Pediatr Rev 2022; 43:572-581. [PMID: 36180545 DOI: 10.1542/pir.2022-005657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral palsy is a neurologic disorder characterized by a spectrum of motor and cognitive deficits resulting from insults to the developing brain. The etiologies are numerous and likely multifactorial; an increasing portion of cases may be attributable to genetic causes, although the exact mechanisms responsible remain poorly understood. Major risk factors include intrauterine stroke and prematurity and neonatal infection, trauma, and hypoxia, which may occur in the prenatal, perinatal, or postnatal period. The Gross Motor Function Classification System (GMFCS) is a widely used tool to establish a child's level of function and to guide treatment; however, additional metrics are necessary to formulate long-term prognoses. Goals of care are to maximize function and independence, which directly correlate with overall quality of life, and family participation is key to establishing goals early in treatment. Nonpharmaceutical treatments include physical, occupational, and speech therapy, as well as bracing, equipment, and technology. There is a breadth of medical interventions for managing hypertonia, including medications, botulinum toxin injections, intrathecal baclofen pumps, and selective dorsal rhizotomy. Orthopedic interventions are indicated for symptomatic or progressive musculoskeletal sequelae. Treatments for dysplastic hips and/or hip instability range from soft tissue releases to bony procedures. Neuromuscular scoliosis is managed with posterior spinal fusion because bracing is ineffective against these rapidly progressive curves. The degree of care varies considerably depending on the child's baseline GMFCS level and functional capabilities, and early screening, diagnosis, and appropriate referrals are paramount to initiating early care and maximizing the child's quality of life.
Collapse
Affiliation(s)
- Jonathan Sheu
- Department of Orthopedic Surgery, McLaren Flint Regional Hospital, Flint, MI
| | - Dorian Cohen
- Department of Orthopedic Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY
| | - Ted Sousa
- Department of Orthopedic Surgery, Shriners Hospital for Children, Spokane, WA
| | - Kelly L D Pham
- Department of Physical Medicine and Rehabilitation, Pediatric Rehabilitation Medicine, Reach Pediatric Rehab, Vienna, VA
| |
Collapse
|
7
|
Peeters N, Papageorgiou E, Hanssen B, De Beukelaer N, Staut L, Degelaen M, Van den Broeck C, Calders P, Feys H, Van Campenhout A, Desloovere K. The Short-Term Impact of Botulinum Neurotoxin-A on Muscle Morphology and Gait in Children with Spastic Cerebral Palsy. Toxins (Basel) 2022; 14:676. [PMID: 36287944 PMCID: PMC9607504 DOI: 10.3390/toxins14100676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 08/27/2023] Open
Abstract
Children with spastic cerebral palsy (SCP) are often treated with intramuscular Botulinum Neurotoxin type-A (BoNT-A). Recent studies demonstrated BoNT-A-induced muscle atrophy and variable effects on gait pathology. This group-matched controlled study in children with SCP compared changes in muscle morphology 8-10 weeks post-BoNT-A treatment (n = 25, median age 6.4 years, GMFCS level I/II/III (14/9/2)) to morphological changes of an untreated control group (n = 20, median age 7.6 years, GMFCS level I/II/III (14/5/1)). Additionally, the effects on gait and spasticity were assessed in all treated children and a subgroup (n = 14), respectively. BoNT-A treatment was applied following an established integrated approach. Gastrocnemius and semitendinosus volume and echogenicity intensity were assessed by 3D-freehand ultrasound, spasticity was quantified through electromyography during passive muscle stretches at different velocities. Ankle and knee kinematics were evaluated by 3D-gait analysis. Medial gastrocnemius (p = 0.018, -5.2%) and semitendinosus muscle volume (p = 0.030, -16.2%) reduced post-BoNT-A, but not in the untreated control group, while echogenicity intensity did not change. Spasticity reduced and ankle gait kinematics significantly improved, combined with limited effects on knee kinematics. This study demonstrated that BoNT-A reduces spasticity and partly improves pathological gait but reduces muscle volume 8-10 weeks post-injections. Close post-BoNT-A follow-up and well-considered treatment selection is advised before BoNT-A application in SCP.
Collapse
Affiliation(s)
- Nicky Peeters
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Britta Hanssen
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Lauraine Staut
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Marc Degelaen
- Inkendaal Rehabilitation Hospital, 1602 Vlezenbeek, Belgium
- Rehabilitation Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | | | - Patrick Calders
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | - Hilde Feys
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Anja Van Campenhout
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Orthopedic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Clinical Motion Analysis Laboratory, University Hospitals Leuven, Pellenberg, 3212 Leuven, Belgium
| |
Collapse
|
8
|
Efficacy of Rehabilitation Therapy and Pharmacotherapy on Children with Cerebral Palsy: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6465060. [PMID: 35855834 PMCID: PMC9288332 DOI: 10.1155/2022/6465060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Abstract
Background. Cerebral palsy (CP) has a serious impact on children’s multiple motor functions and life behavior. Rehabilitation therapy or pharmacotherapy alone has been proven to have a good effect on patients’ strength and gait. However, the efficacy of rehabilitation combined with pharmacotherapy for CP in children needs to be further explored. This study is aimed at assessing the effectiveness of this combined method on life function and social behavior in children with CP. Methods. PubMed, China National Knowledge Infrastructure, WanFang Data, EMBASE, and Web of Science databases were searched for all kinds of literature related to the treatment of pediatric CP published between 2000 and 2021. Basic information and experimental data from the literature were screened and extracted, and a meta-analysis was performed using Stata 16. Results. A total of 605 studies were retrieved, and finally, 10 studies involving 805 pediatric patients were included in the analysis. The analysis results showed that rehabilitation combined with pharmacotherapy could improve the treatment effective rate in children with CP compared with the control group using either alone (
, 95% CI (1.102, 1.273),
). In addition, in terms of social behavior, the combined therapy could significantly improve activities of daily living (
, 95% CI (1.66, 4.22),
), motor ability (
, 95% CI (0.75, 2.96),
), adaptability behavior (
, 95% CI (0.45, 5.18),
), language behavior (
, 95% CI (0.95, 5.22),
), social behavior (
, 95% CI (2.22, 5.35),
), and fine motor behavior (
, 95% CI (1.17, 5.86),
). Conclusion. The current study shows that rehabilitation combined with pharmacotherapy can effectively improve the recovery, quality of life, and social behavior of children with CP.
Collapse
|
9
|
Green MM, Kim H, Gauden R, Scheinberg A, Schroeder AS, Heinen F, Berweck S, Hong BY, Gormley M. Needlepoints: Clinical approach to child living with cerebral palsy. J Pediatr Rehabil Med 2022; 15:91-106. [PMID: 35275576 DOI: 10.3233/prm-220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Heakyung Kim
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ruth Gauden
- The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Adam Scheinberg
- The Royal Children's Hospital Melbourne, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia
| | | | | | | | - Bo Young Hong
- St. Vincent's Hospital, Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Mark Gormley
- Gillette Children's Specialty Healthcare, St.Paul, MN, USA
| |
Collapse
|
10
|
Sozbilen MC, Evren Sahin K. Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy. J Orthop 2021; 29:22-27. [PMID: 35027815 PMCID: PMC8731691 DOI: 10.1016/j.jor.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia. METHODS Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time. RESULTS Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures. CONCLUSIONS As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Murat Celal Sozbilen
- Department of Orthopaedic Surgery, School of Medicine Hospital, Ege University, Bornova, Izmir, Turkey,Corresponding author.
| | - Kubra Evren Sahin
- Department of Anesthesiology and Reanimation, Dr Behcet Uz Child Diseases and Surgery Research and Training Hospital, Konak, Izmir, Turkey
| |
Collapse
|
11
|
O'Flaherty SJ, Stewart K. Current Australian clinical practice in use of botulinum toxin-A to manage paediatric hypertonicity. J Paediatr Child Health 2021; 57:1662-1665. [PMID: 34036660 DOI: 10.1111/jpc.15589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 05/01/2021] [Accepted: 05/16/2021] [Indexed: 11/29/2022]
Abstract
AIM To describe current rehabilitation paediatricians' use of intramuscular botulinum toxin-A (BoNT-A) to manage hypertonicity. METHODS Cross-sectional survey. RESULTS In late 2019, 32 of the 35 identified Australian rehabilitation paediatricians who use BoNT-A to manage paediatric hypertonicity completed the survey. Annually, they administer just over 3750 courses of BoNT-A to manage hypertonicity with a mean of 11 years of clinical experience. Sedation was used by all but 1 clinician who used a number of other strategies during the procedure. Mean (and median) maximum dose of OnabotulinumtoxinA (Botox) was 400 Units (range 300-450 Units). Only three clinicians indicated that they used AbobotulinumtoxinA (Dysport) - the other BoNT-A preparation approved for children available in Australia; analysis of its use was not performed. Dose modifications were made by clinicians according to a patient's response to a previous course of BoNT-A (88% of respondents); patient experience of a previous adverse event (78%); history of aspiration or dysphagia (65 and 63%, respectively); and the presence of dystonia; and where the patient was GMFCS level V (53% each). Intervals between courses ranged from 3 to 24 months with the variation due to clinical circumstances. CONCLUSION Clinical practice in BoNT-A management of paediatric hypertonicity was largely consistent in regard to maximum doses of OnabotulinumtoxinA (Botox) used. Dose modification and time between injection courses varied according to individual clinical presentation. Procedural sedation was used extensively.
Collapse
Affiliation(s)
| | - Kirsty Stewart
- KidsRehab, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
Collapse
Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | |
Collapse
|
13
|
Danzig JA, Katz EB. Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management. Curr Probl Pediatr Adolesc Health Care 2021; 51:101074. [PMID: 34656455 DOI: 10.1016/j.cppeds.2021.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.
Collapse
Affiliation(s)
- Jennifer A Danzig
- Division of General Pediatrics, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Elana B Katz
- Center for Rehabilitation, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| |
Collapse
|
14
|
Bekkers S, Leow TYS, Van Hulst K, Orriëns LB, Scheffer ART, Van Den Hoogen FJA. Repeated onabotulinum neurotoxin A injections for drooling in children with neurodisability. Dev Med Child Neurol 2021; 63:991-997. [PMID: 33772779 PMCID: PMC8359949 DOI: 10.1111/dmcn.14872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the effect of repeated onabotulinum neurotoxin A injections for the treatment of drooling in children with neurodisabilities. METHOD This was a retrospective cohort study, in which the first, second, and third onabotulinum neurotoxin A injection were compared within children treated between 2000 and 2020. Primary outcomes included drooling quotient, visual analogue scale (VAS), and treatment success defined as ≥50% reduction in drooling quotient and/or VAS 8 weeks after treatment. Each outcome was obtained at baseline and 8 weeks posttreatment. RESULTS Seventy-seven children were included (mean age at first injection: 8y 3mo, SD 3y 7mo, range 3-17y; 44 males, 33 females; 51.9% with cerebral palsy, 45.5% wheelchair-bound). The objective (drooling quotient) and subjective (VAS) effect after the second injection was lower compared to the first injection. The third injection showed less objective and significantly less subjective effect compared to the first injection. An overall success rate of 74.0%, 41.6%, and 45.8% were found for the first, second, and third injection respectively. INTERPRETATION Although onabotulinum neurotoxin A remained effective throughout the entire treatment course, there is less effect of subsequent onabotulinum neurotoxin A injections compared to the first. Although there might be a loss of effect after repeated injections, there is continued improvement for most children. What this paper adds Repeated injections show a diminished treatment effect after the second injection. A continued improvement is seen in most patients.
Collapse
Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Theresa YS Leow
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Karen Van Hulst
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Lynn B Orriëns
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Arthur RT Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Frank JA Van Den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| |
Collapse
|
15
|
Long-term effect of botulinum toxin A on the hip and spine in cerebral palsy: A national retrospective cohort study in Taiwan. PLoS One 2021; 16:e0255143. [PMID: 34293010 PMCID: PMC8297884 DOI: 10.1371/journal.pone.0255143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/09/2021] [Indexed: 11/19/2022] Open
Abstract
Objectives To investigate the effect of botulinum toxin A (BTA) on the development of hip dislocation and scoliosis, surgical rates for hip and spine, and mortality in cerebral palsy (CP). Study design A cohort study was conducted using CP data from a Taiwan National Insurance Health Research Database. Diagnoses were defined using the International Classification of Diseases codes, 9th revision. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis and adjusted for the following variables: BTA injection, sex, age, severities of CP, comorbidities, location, urbanization level, and level of care. Results A total of 1,405 CP children (670 female vs. 735 male), 281 in the BTA group and 1,124 in the controls, were followed-up for a mean of 5 years 4 months. There were no significant differences in the outcomes in both groups, in the incidence rates of hip dislocation and scoliosis, nor in the surgical rates for hip and spine surgery. Mortality rate in the BTA group was 0.49 times lower than that in the controls (p = 0.001). Moderate to severe types of CP had higher incidence rates of hip dislocation, scoliosis, hip surgery, spine surgery, and mortality. Conclusion Moderate to severe types of CP had poorer outcomes in all aspects, including a higher risk of hip dislocation, scoliosis, surgical rate for hip and spine, and mortality. Although BTA injection in children with CP proved to not significantly reduce hip dislocation and scoliosis, it is considered safe as an anti-spasticity treatment and may be beneficial for survival.
Collapse
|
16
|
Kuroda MM, Mutsuzaki H, Yoshikawa K, Ohguro H, Nobuaki I. Gait training using a hybrid assistive limb after botulinum toxin treatment for cerebral palsy: a case report. J Phys Ther Sci 2021; 33:499-504. [PMID: 34177115 PMCID: PMC8219601 DOI: 10.1589/jpts.33.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/26/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Hybrid Assistive Limb® (HAL; Cyberdyne, Tsukuba, Japan) is a wearable robot that assists patients based on their voluntary movements. We report gait training with HAL after botulinum toxin treatment for spasticity of the lower limb in cerebral palsy (CP). [Participant and Methods] The participant was a 36 year-old male with spastic diplegia due to periventricular leukomalacia, with Gross Motor Function Classification System (GMFCS) level II. HAL training was performed in 20-minute sessions (3 sessions/week for 4 weeks). The outcome measures were range of motion, spasticity, walking ability, muscle strength, gross motor function measure (GMFM), Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, immediately after, and one, two, and three months after HAL training. [Results] No adverse events were observed during training. After the HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), knee extension strength, GMFM, and COPM increased, and Physiological Cost Index declined. Three months post-intervention, gait speed, step length, cadence, 6MD, and GMFM remained higher than those observed within the first two months. [Conclusion] Gait training with HAL can be a safe and feasible method for patients with CP who undergo botulinum toxin treatment to improve walking ability and motor function.
Collapse
Affiliation(s)
- Mayumi Matsuda Kuroda
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ami-machi, Ibaraki 300-0394, Japan
| | - Hirotaka Mutsuzaki
- Center for Medical Science, Ibaraki Prefectural University of Health Sciences, Japan
| | - Kenichi Yoshikawa
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Haruka Ohguro
- Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Iwasaki Nobuaki
- Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| |
Collapse
|
17
|
Farag SM, Mohammed MO, El-Sobky TA, ElKadery NA, ElZohiery AK. Botulinum Toxin A Injection in Treatment of Upper Limb Spasticity in Children with Cerebral Palsy: A Systematic Review of Randomized Controlled Trials. JBJS Rev 2021; 8:e0119. [PMID: 32224633 PMCID: PMC7161716 DOI: 10.2106/jbjs.rvw.19.00119] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is the most common cause of childhood disability globally. Botulinum toxin A injections are widely used to manage limb spasticity in children with CP. Intramuscular botulinum toxin A has been used in the upper limbs of children with CP to manage preoperative and postoperative pain, facilitate nursing, and achieve functional and/or cosmetic improvement of hand position. These goals are achieved primarily through reduction of spasticity. The aim of this review was to assess the evidence for the effect of botulinum toxin A injections used to manage upper limb spasticity in children with spastic CP. Specifically, we examined the role of botulinum toxin A as an adjunctive treatment to other physical therapy modalities. Additionally, we analyzed the associated complications. METHODS The literature extraction process involved 4 phases: identification, screening, eligibility, and inclusion. We used a combination of Google Scholar, PubMed, and ScienceDirect. The choice of the search terms was based on the Medical Subject Headings. We extracted the relevant studies using a combination of words or terms related to (1) patient population, (2) pathology, (3) clinical intervention, and (4) anatomical distribution of pathology. Studies were included if they were randomized controlled trials conducted on children and/or adolescents with CP targeting the upper extremities in which botulinum toxin A was used as an adjunctive treatment to a primary intervention. RESULTS The literature extraction process yielded 15 randomized controlled trials for inclusion in this review. The total number of participants enrolled in the included studies was 499, with 255 in the intervention group (51%) and 244 controls (49%). All participants in the eligible studies had unilateral spastic CP except for those in 4 studies (27%) with 198 participants (40%) that included a heterogeneous sample of unilateral and bilateral spastic CP. The mean age of participants in the intervention group ranged from 2.6 to 10.7 years among the individual studies. The mean age of participants in the control group ranged from 3.1 to 10.55 years among the individual studies. This review indicated that botulinum toxin A had a positive effect on the degree of spasticity and cosmetic appearance of the injected upper limb. The results with respect to functional gains and quality of life were either conflicting or not significant. CONCLUSIONS Randomized controlled trials of botulinum toxin A injection in the treatment of upper limb spasticity in children with CP used variable outcome measures and yielded mixed results. Overall, there is some evidence to support the use of botulinum toxin A as an adjuvant treatment to other physical therapy regimens or placebo to reduce spasticity in the short term. There is insufficient evidence to support its use as an adjunctive treatment to improve upper limb function or quality of life. The complications were acceptable and did not outweigh the clinical gains incurred. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Sara M Farag
- Department of Physical Medicine and Rehabilitation, National Institute of Neuromuscular Disorders, Cairo, Egypt
| | - Manal O Mohammed
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
| | - Tamer A El-Sobky
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt.,Department of Pediatric Orthopedics, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
| | - Nadia A ElKadery
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
| | - Abeer K ElZohiery
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
| |
Collapse
|
18
|
Fujimoto J, Umemoto Y, Koike Y, Isida K, Sakamoto K, Tajima F. Immediate effects of short period lower limb ergometer exercise in adolescent and young adult patients with cerebral palsy and spastic diplegia. J Phys Ther Sci 2021; 33:52-56. [PMID: 33519075 PMCID: PMC7829563 DOI: 10.1589/jpts.33.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/25/2020] [Indexed: 11/24/2022] Open
Abstract
[Purpose] To determine the effects of lower limb ergometer exercise on the spasticity and joint range of motion of the lower extremity and gait function in patients with cerebral palsy and spastic paralysis. [Participants and Methods] This study included 8 participants with cerebral palsy and spastic paralysis (GMFCS levels I to IV) who received care at the outpatient clinic. After a 5-min rest, the lower limb ergometer exercises were performed for 10 min. We measured the participants' arterial blood pressure, pulse rate, passive range of knee joint extension, muscle tone using the Modified Ashworth scale (MAS) and Modified Tardieu scale (MTS), and 10-m walk test (10MWT). Measurements were collected three times (at baseline before exercise, immediately at the end of exercise, and 5 min after exercise during recovery). [Results] The 10-min lower limb ergometer exercise significantly improved the knee joint extension, MAS and MTS scores, and reduced lower extremity spasticity. Furthermore, it significantly increased the range of knee joint extension and decreased the 10MWT score. [Conclusion] The results showed that the 10-minute lower limb ergometer exercise is beneficial in reducing the spasticity of the lower limb muscles and in increasing the range of motion of knee extension in paraplegic patients with cerebral palsy, suggesting that its implementation in young children could prevent spasticity and enhance motor function.
Collapse
Affiliation(s)
- Junpei Fujimoto
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan.,Aitoku Medical Welfare Center, Japan
| | - Yasunori Umemoto
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan
| | - Yumi Koike
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan
| | - Kazuya Isida
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan
| | - Keiko Sakamoto
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University: 811-1 Kimiidera, Wakayama city, Wakayama 641-8509, Japan
| |
Collapse
|
19
|
McLaughlin M, Inanoglu D. Decreased clinical response to therapy in pediatric patients with cerebral palsy: Current trends and challenges. J Pediatr Rehabil Med 2021; 14:307-314. [PMID: 34092663 DOI: 10.3233/prm-210028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Matthew McLaughlin
- University of Missouri-Kansas City School of Medicine, Children's Mercy - Kansas City, Kansas City, MO, USA
| | - Didem Inanoglu
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
20
|
The utility of shear wave elastography in the evaluation of muscle stiffness in patients with cerebral palsy after botulinum toxin A injection. J Med Ultrason (2001) 2020; 47:609-615. [PMID: 32705628 DOI: 10.1007/s10396-020-01042-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
Abstract
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.
Collapse
|
21
|
Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
Collapse
Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
| |
Collapse
|
22
|
Campbell R, Tipping N, Carty C, Walsh J, Johnson L. Orthopaedic management of knee joint impairment in cerebral palsy: A systematic review and meta-analysis. Gait Posture 2020; 80:347-360. [PMID: 32615408 DOI: 10.1016/j.gaitpost.2020.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/01/2020] [Accepted: 06/14/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The optimal management of impaired knee joint function in patients with cerebral palsy (CP) remains a significant and ongoing challenge in paediatric orthopaedic surgery. RESEARCH QUESTION What are the clinical and functional outcomes after operative and non-operative orthopaedic interventions for knee joint impairment in patients with CP? METHODS This systematic review and meta-analysis of orthopaedic interventions for the management of knee joint impairment in paediatric CP patients evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. We performed searches of the following electronic databases from their dates of inception to November 2019: Medline (Ovid), Embase (Ovid) and Pubmed. We extracted mean differences in pre-operative and post-operative measurements for the following outcomes: minimum knee flexion in stance; knee flexion at initial contact; maximum knee flexion in swing; range of motion; popliteal angle; fixed flexion deformity angle; and mean pelvic tilt. RESULTS Sixty-nine retrospective cohort studies, prospective cohort studies and RCTs comprising 2991 patients were included with 4578 knees analysed. Included studies were of sufficient quality as assessed by the MOOSE checklist. Operative interventions showed significant improvement in knee flexion at initial contact, knee flexion in stance, range of motion, popliteal angle and fixed flexion deformity which were comparable when subgrouped according to operative technique. In contrast, non-operative techniques and botulinum toxin injection did not confer significant improvements. Operative interventions for knee joint impairment led to increased mean pelvic tilt and reduced maximum knee flexion in swing. SIGNIFICANCE This review provides strong evidence that operative interventions for the management of knee joint impairment in cerebral palsy patients improve knee kinematics and clinical examination findings.
Collapse
Affiliation(s)
- Ryan Campbell
- Department of Medicine, University of New South Wales, Australia.
| | - Nicholas Tipping
- Department of Medicine, University of New South Wales, Australia
| | - Christopher Carty
- School of Allied Health Sciences and GCORE, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD 4222, Australia; Department of Orthopaedics, Queensland Children's Hospital, QLD 4101, Australia
| | - John Walsh
- Department of Orthopaedics, Queensland Children's Hospital, QLD 4101, Australia
| | - Liam Johnson
- Department of Orthopaedics, Queensland Children's Hospital, QLD 4101, Australia
| |
Collapse
|
23
|
Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Namara MM, Paton MC, Popat H, Shore B, Khamis A, Stanton E, Finemore OP, Tricks A, Te Velde A, Dark L, Morton N, Badawi N. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 2020; 20:3. [PMID: 32086598 PMCID: PMC7035308 DOI: 10.1007/s11910-020-1022-z] [Citation(s) in RCA: 409] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.
Collapse
Affiliation(s)
- Iona Novak
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia.
| | - Catherine Morgan
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Michael Fahey
- Department of Paediatric Neurology, Monash Health, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Megan Finch-Edmondson
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Claire Galea
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ashleigh Hines
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Katherine Langdon
- Department of Paediatric Rehabilitation, Kids Rehab WA, Perth Children's Hospital, Perth, Australia
| | - Maria Mc Namara
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Madison Cb Paton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Himanshu Popat
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Benjamin Shore
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda Khamis
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Emma Stanton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Olivia P Finemore
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Alice Tricks
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Anna Te Velde
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Leigha Dark
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Natalie Morton
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- School of Allied Health, Australian Catholic University, North Sydney, New South Wales, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| |
Collapse
|
24
|
Lidman GRM, Nachemson AK, Peny-Dahlstrand MB, Himmelmann KME. Long-term effects of repeated botulinum neurotoxin A, bimanual training, and splinting in young children with cerebral palsy. Dev Med Child Neurol 2020; 62:252-258. [PMID: 31225647 DOI: 10.1111/dmcn.14298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 11/28/2022]
Abstract
AIM To investigate long-term development of hand function after repeated botulinum neurotoxin A (BoNT-A) and occupational therapy at a young age. METHOD Twenty children with unilateral spastic cerebral palsy (CP) (14 males, six females; median inclusion age 3y 1mo, range 1y 11mo-4y 3mo) participated in this longitudinal study. Ten children received occupational therapy after a randomized controlled trial and 10 repeated BoNT-A plus occupational therapy during 1-year. The Assisting Hand Assessment (AHA) and active supination, assessed the following 3 years. The assessments were compared with data from a reference group to investigate development over time. RESULTS The improvement in AHA (7.5 AHA units) after BoNT-A plus occupational therapy was maintained at final follow-up. The occupational therapy group, unchanged after 1-year, improved by 5 AHA units (96% confidence interval [CI] 2-10), thus there was no difference between the groups. Median active supination increased in comparison with the reference group. In the BoNT-A/occupational therapy group, 9 out of 10 (97.85% CI 45 115) children improved in active supination. In the occupational therapy group, 7 out of 10 (97.85% CI -2 to 68) children improved in active supination. No correlation between active supination and AHA was found. INTERPRETATION Bimanual performance achieved after BoNT-A plus occupational therapy was maintained, while it increased by follow-up in the occupational therapy group, suggesting that combined intervention gave earlier access to bimanual skills. Active supination was unrelated to AHA. WHAT THIS PAPER ADDS Children whose bimanual performance improved after botulinum neurotoxin A and/or occupational therapy, maintained skills or progressed during follow-up. Bimanual performance increased with age, similar to a quality-register reference group. Increased active supination after intervention improved at follow-up but was not related to bimanual performance.
Collapse
Affiliation(s)
- Git R M Lidman
- Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ann K Nachemson
- Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie B Peny-Dahlstrand
- Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kate M E Himmelmann
- Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Paediatrics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
25
|
Valentine J, Davidson SA, Bear N, Blair E, Paterson L, Ward R, Forbes D, Elliott C. A prospective study investigating gross motor function of children with cerebral palsy and GMFCS level II after long-term Botulinum toxin type A use. BMC Pediatr 2020; 20:7. [PMID: 31906902 PMCID: PMC6945782 DOI: 10.1186/s12887-019-1906-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to contribute to the knowledge base on the long-term outcomes of evidence-based medical interventions used to improve gross motor function in children and adolescents with Cerebral Palsy. METHOD Prospective cohort study of children with Cerebral Palsy in the birth years 2000-2009 attending a tertiary level service for children with Cerebral Palsy who's first recorded Gross Motor Function Classification System level was II. RESULTS A total of 40 children were eligible for the study, of whom 28 (72.7%) enrolled. The Botulinum toxin A treatment for this cohort, (median and interquartile ranges) were: total number of lower limb Botulinum toxin A injections 11 (6.7, 5.5); total dose of Botulinum Toxin A per lower limb treatment 6.95 u/kg (4.5, 11); and dose of Botulinum Toxin u/kg/muscle 2.95 (2.2, 4). For all 28 subjects there was a median of 15 (8.5 to 22) Gross Motor Function Classification System level recordings: six of the 28 children (21.4%) improved from level II to level I, the remaining 22 children remained stable at level II (78.6%). In this highly treated population, the average 66 item Gross Motor Function Measure score for the 22 children in level II was 72.55, which is consistent with the mean of 68.5 reported in the original Ontario cohort. CONCLUSION This cohort study has confirmed that children with Cerebral Palsy, Gross Motor Function level II treated at a young age with repeated doses of Botulinum Toxin A within an integrated comprehensive service, maintain or improve their functional motor level at a later age.
Collapse
Affiliation(s)
- Jane Valentine
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia. .,Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia.
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Nedlands, Western Australia, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Lisa Paterson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| | - David Forbes
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia
| | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| |
Collapse
|
26
|
Kim HJ, Park JW, Nam K. Effect of extracorporeal shockwave therapy on muscle spasticity in patients with cerebral palsy: meta-analysis and systematic review. Eur J Phys Rehabil Med 2020; 55:761-771. [PMID: 31615195 DOI: 10.23736/s1973-9087.19.05888-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Recently, clinical trials have been performed to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) in patients with cerebral palsy (CP). However, various studies adopted different clinical scales, making it insufficient to draw a definite conclusion about the efficacy of ESWT in reducing spasticity after cerebral palsy. The purpose of this meta-analysis was to assess the effects of ESWT on reducing spasticity after applying ESWT in patients with CP. EVIDENCE ACQUISITION In accordance with the PRISMA statement, authors searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and Scopus from their inception dates through December 11th 2018. We included randomised controlled trials in any language that using ESWT for the purpose of ameliorating spasticity in patients with CP. We assessed spasticity measured by modified Ashworth Scale (MAS), range of motion (ROM) and baropodometric values as outcomes. EVIDENCE SYNTHESIS Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesised narratively. From a total of 206 articles, 16 manuscripts were selected and 5 of them were ultimately included in this meta-analysis. MAS grade as primary outcome was significantly improved after ESWT compared to that in the control group (mean difference [MD]: -0.62; 95% CI: -1.52 to -0.18). ROM after ESWT was also significantly improved compared to that in the control groups (MD: 18.01; 95% CI: 6.11 to 29.91). Baropodometric measures showed significantly increases in foot contact area during gait (SMD: 29.00; 95% CI: 11.08 to 46.92), but not significantly in peak pressure under the heel (MD: 15.12; 95% CI: -1.85 to 32.10) immediately after ESWT. CONCLUSIONS No serious side effects were observed in any patient after ESWT. ESWT may be a valid alternative to existing treatment options targeting spasticity diminishment and ROM improvement in CP patients to maintain healthy lifestyles and normalize spastic gait pattern. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow-up studies are needed to verify our results.
Collapse
Affiliation(s)
- Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jin-Woo Park
- Department of Physical Medicine and Rehabilitation, Dongguk University College of Medicine, Goyang, South Korea
| | - Kiyeun Nam
- Department of Physical Medicine and Rehabilitation, Dongguk University College of Medicine, Goyang, South Korea -
| |
Collapse
|
27
|
The Effect of Botulinum Toxin Injections on Gross Motor Function for Lower Limb Spasticity in Children with Cerebral Palsy. Toxins (Basel) 2019; 11:toxins11110651. [PMID: 31717282 PMCID: PMC6891294 DOI: 10.3390/toxins11110651] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to investigate the use of botulinum toxin type A (BoNT-A) injections and their efficacy on gross motor function for lower limb spasticity in children with spastic cerebral palsy (CP). This retrospective study included 919 injection occasions from 591 children with CP who received a lower limb BoNT-A injection between 2006 and 2016. The Gross Motor Function Measure (GMFM-88), the Modified Ashworth Scale, and the Modified Tardieu Scale were administered before and after injections. Injections were predominantly administered to children under the age of 6 years. The most common muscle injection site was the calf muscle for dynamic foot deformity. The second most commonly injected muscle was the hip adductor among 2–3 year olds and the hamstring muscle among 4–6 year olds. Distal injections were predominantly administered to high-functioning children, whereas proximal injections were typically administered to low-functioning children. Multilevel injections were mostly administered to midfunctioning children. GMFM-88 scores significantly increased post-injection for both high- and low-functioning groups. Younger age at injection and distal injection type were associated with larger improvements on the GMFM-88 at both short- and midterm follow-up. The target muscles for injection varied depending on gross motor functioning and age. Younger age at injection and distal injection type were significantly related with greater gain in gross motor function.
Collapse
|
28
|
Sedation-analgesia protocol for the injection of botulinum toxin A in cerebral palsy. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
29
|
Valentine J, Davidson SA, Bear N, Blair E, Ward R, Thornton A, Stannage K, Watson L, Forbes D, Elliott C. Botulinum toxin and surgical intervention in children and adolescents with cerebral palsy: who, when and why do we treat? Disabil Rehabil 2019; 43:936-943. [PMID: 31415723 DOI: 10.1080/09638288.2019.1644381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This audit aimed to increase understanding of the long-term outcomes of evidence-based medical and surgical interventions to improve gross motor function in children and adolescents with Cerebral Palsy. METHODS Retrospective audit of a birth cohort (2000-2009) attending a tertiary service in Western Australia. RESULTS The cohort comprises 771 patients aged 8 to 17 years. Percentage of children receiving no Botulinum Toxin treatments in each Gross Motor Functional Classification System level was: I: 40%, II: 26%, III: 33%, IV: 28% and V: 46%. Of the total cohort, 53% of children received 4 or less Botulinum Toxin treatments and 3.7% received more than 20 treatments. Statistically significant difference in the rate of use of Botulinum Toxin pre and post-surgery (p < 0.001) was documented. Children levels IV and V had 5 times the odds of surgery compared to children levels I-III (Odds Ratio 5.2, 95% Confidence Interval 3.5 to 7.8, p < 0.001). For 578 (75%) of participants the last recorded level was the same as the first. CONCLUSION This audit documents medical intervention by age and Gross Motor Functional Classification System level in a large cohort of children with cerebral palsy over time and confirms stability of the level in the majority.IMPLICATIONS FOR REHABILITATIONThe information from this audit may be of use in discussions with families regarding the timing and use of Botulinum toxin and surgical intervention for motor function in children and adolescents with Cerebral Palsy.Long term use of Botulinum Toxin within an integrated evidence-based clinical program is not associated with loss of gross motor function in the long term as evidenced by the maintenance of Gross Motor Functional Classification System stability.
Collapse
Affiliation(s)
- Jane Valentine
- School of Medicine University of Western Australia, Perth, Australia
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Perth, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Perth, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Ashleigh Thornton
- School of Medicine University of Western Australia, Perth, Australia
| | - Katherine Stannage
- Department of Orthopaedic Surgery, Perth Children's Hospital, Perth, Australia
| | - Linda Watson
- WA Register of Developmental Anomalies, King Edward Memorial Hospital, Subiaco, Australia
| | | | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| |
Collapse
|
30
|
Yan Y, Fu X, Xie X, Ji S, Luo H, Yang F, Zhang X, Yang S, Xie P. Hip Adductor Intramuscular Nerve Distribution Pattern of Children: A Guide for BTX-A Treatment to Muscle Spasticity in Cerebral Palsy. Front Neurol 2019; 10:616. [PMID: 31258508 PMCID: PMC6587062 DOI: 10.3389/fneur.2019.00616] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/24/2019] [Indexed: 12/29/2022] Open
Abstract
To investigate the intramuscular nerve distribution pattern in the hip adductors of children and to precisely locate the injection site for botulinum toxin type A (BTX-A) as a treatment for hip adductor spasticity in children with cerebral palsy. Modified Sihler's whole mount nerve staining technique was employed to observe the distribution of intramuscular nerves in hip adductors of children and to further locate zones where terminal nerves are concentrated. The terminal nerves of the adductor longus appeared in a longitudinal distribution band parallel to the line between the upper 1/3 point of the lateral boundary and the center of the medial boundary. In adductor brevis, the terminal nerves showed a sheet-like distribution with a nerve dense area located in the middle of the muscle belly that extends from the upper-inner region to the lower-outer region. Gracilis showed a dense area of terminal nerves in the middle of the muscle belly, closer to the posterior boundary. In adductor magnus, the dense area of terminal nerves showed a sheet-like distribution in the middle and lower region of the muscle belly. The dense area of terminal nerves in the pectineus was located in the middle of the muscle belly. This study is the first to systematically investigate the intramuscular nerve distribution pattern in the hip adductors. The results indicated that the best targets for BTX-A injection, when treating spasticity, are the dense regions of terminal nerves described above.
Collapse
Affiliation(s)
- Yan Yan
- Department of Anatomy, Zunyi Medical University, Zunyi, China.,Department of Critical Care Medicine of the Third Affiliated Hospital, Zunyi Medical University, Zunyi, China
| | - Xiaoyun Fu
- Department of Critical Care Medicine of the Affiliated Hospital, Zunyi Medical University, Zunyi, China
| | - Xiadan Xie
- Department of Biochemistry, Zunyi Medical University, Zunyi, China
| | - Songling Ji
- Department of Anatomy, Zunyi Medical University, Zunyi, China
| | - Huaixiang Luo
- Department of Anatomy, Zunyi Medical University, Zunyi, China
| | - Fangjiu Yang
- Department of Anatomy, Zunyi Medical University, Zunyi, China
| | - Xiaoming Zhang
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, United States
| | - Shengbo Yang
- Department of Anatomy, Zunyi Medical University, Zunyi, China
| | - Peng Xie
- Department of Critical Care Medicine of the Third Affiliated Hospital, Zunyi Medical University, Zunyi, China
| |
Collapse
|
31
|
[Sedation-analgesia protocol for the injection of botulinum toxin A in cerebral palsy]. An Pediatr (Barc) 2019; 91:317-327. [PMID: 30795881 DOI: 10.1016/j.anpedi.2018.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/05/2018] [Accepted: 12/27/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the impact of the sedation-analgesia technique on the pain experienced by the patient. METHODS This cross-sectional study was conducted on consecutive patients with cerebral palsy (CP) who underwent infiltration with botulinum toxin A (BoTNA). The patients were divided into 4 different groups according to the analgesic strategy assigned: Group I, without sedation or topical anaesthetic cream; Group II, inhalation of nitrous oxide; Group III, deep intravenous sedation; and Group IV, light sedation with benzodiazepines. Pain was assessed with different scales depending on patient age. Parents were asked to rate their satisfaction with their child's comfort by using a 5-point Likert-type scale. The primary end-point was the proportion of patients that experienced a pain level equal or lower than 2, according to pain scales, in the different study groups. RESULTS Of the 124 patients included in the study, 56 (45.2%) experienced a pain level ≤2. In the Group III a significantly greater proportion of patients were classified with a pain level score ≤2, P<.001, as compared with all the study groups, respectively. The BoTNA injection was guided by ultrasonography in 109 (87.9%) patients, and by palpation in 15 (12.1%). CONCLUSION The results of this study suggested that, in patients with CP treated with BoTNA injections, the sedation-analgesic strategy had a significant impact on the pain experienced by the subject. Selecting an appropriate analgesic strategy is crucial for reducing the stress associated with the administration of BoTNA injections in children with CP.
Collapse
|
32
|
Effectiveness of multiple botulinum toxin sessions and the duration of effects in spasticity therapy in children with cerebral palsy. Childs Nerv Syst 2019; 35:141-147. [PMID: 30058050 PMCID: PMC6341047 DOI: 10.1007/s00381-018-3923-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to assess the effectiveness of long-term therapy with multiply botulinum neurotoxin (BoNT) injections. METHODS In 2004-2010, 60 children with spastic cerebral palsy aged 2-16 were treated multiple botulinum toxin sessions (injections in gastrocnemius muscle and soleus muscles). In each patient, we rated muscle tone by Modified Ashworth Scale, passive range of motion in ankle joint with extended, and flexed knee joint and gait using the Physician Rating Scale. Assessment was done before and after injection, up to eight BoNT sessions. RESULTS The generalized additive models showed that a single treatment effect was visible for 3 months. The number of injections did not impact the effectiveness. Improvement in muscle tone was greater in children with hemiplegia than diplegia (β = - 0.294; p = 0.014). Improvement in range of motion with extended knee joint was greater in hemiplegic than diplegic types (β = 0.414; p =0.002), and improvement in range of motion with flexed knee was greater in children with more severe impairment (Gross Motor Function Classification System III vs. I, β = 0.0603, p = 0.025; V vs. I, β = 0.691, p = 0.023). The gait improvement rate decreased with patient age (p = 0.007). CONCLUSIONS BoNT therapy is effective regardless of the number of injection sessions and duration of treatment. However, it is affected by the patient's age, type of cerebral palsy, and degree of impairment.
Collapse
|
33
|
Dabrowski E, Bonikowski M, Gormley M, Volteau M, Picaut P, Delgado MR. AbobotulinumtoxinA Efficacy and Safety in Children With Equinus Foot Previously Treated With Botulinum Toxin. Pediatr Neurol 2018; 82:44-49. [PMID: 29625849 DOI: 10.1016/j.pediatrneurol.2017.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/30/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of botulinum toxin are transient, and repeat injections are required in children with lower-limb spasticity. However, the efficacy of botulinum toxin in patients who have received previous injections has remained largely unexplored. METHODS We present subgroup analyses of a phase III study conducted in ambulatory children (aged two to 17) with spastic equinus foot. Patients were randomized to single doses of abobotulinumtoxinA 10 U/kg/leg, 15 U/kg/leg, or placebo injected into the gastrocnemius-soleus complex (one or both legs). The first analysis was prespecified to review the effect of abobotulinumtoxinA in children previously treated with botulinum toxin versus those children new to the treatment; a second post hoc analysis evaluated the effect of abobotulinumtoxinA in children who changed botulinum toxin formulation. RESULTS Of the 241 randomized patients, 113 had previously received botulinum toxin, including 86 who had been treated with another formulation. In both analyses, muscle tone (Modified Ashworth Scale) and the Physicians Global Assessment, at week 4, improved with abobotulinumtoxinA treatment versus placebo, regardless of baseline botulinum toxin status. Placebo responses in patients new to treatment were consistently higher than in the previously treated group. CONCLUSIONS These results demonstrate similar abobotulinumtoxinA efficacy and safety profiles in children with spasticity who are new to botulinum toxin treatment and those children who were previously treated. The efficacy and safety of abobotulinumtoxinA treatment in these previously treated patients were comparable with the overall trial population, indicating that doses of 10 and 15 U/kg/leg are suitable starting doses for children with spasticity regardless of the previous botulinum toxin preparation used.
Collapse
Affiliation(s)
- Edward Dabrowski
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, Michigan.
| | | | - Mark Gormley
- Gillette Children's Specialty Healthcare, St Paul, Minnesota
| | | | | | - Mauricio R Delgado
- Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas, Texas
| |
Collapse
|
34
|
Chau B, Chi B, Wilson T. Decreasing pediatric pain and agitation during botulinum toxin injections for spasticity with virtual reality: Lessons learned from clinical use. J Pediatr Rehabil Med 2018; 11:199-204. [PMID: 30223406 DOI: 10.3233/prm-180534] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Recurrent botulinum toxin (BoNT) injections are used in the pediatric population for management of spasticity, but the procedure is often associated with significant pain and anxiety for patients. Non-pharmacologic treatment alternatives for procedural discomfort are limited. Immersive virtual reality (VR) has shown efficacy in treatment of procedural discomfort in pediatric patients. A retrospective chart review was performed to assess feasibility and use of treating BoNT procedure-related discomfort in pediatric patients with VR. METHODS Fourteen patients undergoing elective BoNT injections viewed VR videos using a mobile VR headset during the procedure. Face, Legs, Activity, Cry, Consolability scale (FLACC) scores were obtained and feedback was elicited following injections. RESULTS The VR intervention was well tolerated, and patients' guardians requested that it be used again in 9/14 cases. The remainder either had high FLACC scores despite VR and neutral or negative guardian impressions of intervention, or were unable to utilize the device. CONCLUSION VR was helpful in reducing BoNT procedure-related discomfort in a majority of patients. Challenges with VR setup, patient tolerance, and selecting viewing experiences were identified to guide further research and use of VR in a clinical environment.
Collapse
Affiliation(s)
- Brian Chau
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, Loma Linda, CA, USA.,Veteran Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Bradley Chi
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, Loma Linda, CA, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Thaddeus Wilson
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, Loma Linda, CA, USA
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
Delgado MR, Bonikowski M, Carranza J, Dabrowski E, Matthews D, Russman B, Tilton A, Velez JC, Grandoulier AS, Picaut P. Safety and Efficacy of Repeat Open-Label AbobotulinumtoxinA Treatment in Pediatric Cerebral Palsy. J Child Neurol 2017; 32:1058-1064. [PMID: 28914131 PMCID: PMC5652649 DOI: 10.1177/0883073817729918] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This was a prospective, repeat-treatment, open-label study (NCT01251380) of abobotulinumtoxinA for the management of lower limb spasticity in children who had completed a double-blind study. Children (2-17 years) received injections into the gastrocnemius-soleus complex, and other distal and proximal muscles as required (maximum total dose per injection cycle: 30 U/kg or 1000U). A total of 216 of the 241 double-blind patients entered the extension study and 207 received ≥1 open label injection into the gastrocnemius-soleus; 17-24% of patients also had injections into the hamstrings. The most frequent adverse events were related to common childhood infections and the most frequent treatment-related adverse event was injection site pain (n = 10). There was no evidence of a cumulative effect on adverse events. Sustained significant clinical improvements in muscle tone (Modified Ashworth Scale), spasticity (Tardieu Scale), overall clinical benefit (Physicians Global Assessment), and goal attainment (Goal Attainment Scale) were also observed across treatment cycles.
Collapse
Affiliation(s)
- Mauricio R Delgado
- 1 University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | | | | | - Edward Dabrowski
- 4 Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI, USA
| | | | - Barry Russman
- 6 Shriner's Hospital for Children, Portland, OR, USA
| | - Ann Tilton
- 7 LSUHSC and Children's Hospital New Orleans, New Orleans, LA, USA
| | - Juan Carlos Velez
- 8 Centro de Rehabilitacion Club De Leones Cruz del Sur, Punta Arenas, Chile
| | | | | |
Collapse
|
37
|
Read FA, Boyd RN, Barber LA. Longitudinal assessment of gait quality in children with bilateral cerebral palsy following repeated lower limb intramuscular Botulinum toxin-A injections. RESEARCH IN DEVELOPMENTAL DISABILITIES 2017; 68:35-41. [PMID: 28735160 DOI: 10.1016/j.ridd.2017.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/28/2017] [Accepted: 07/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Serial lower limb intramuscular Botulinum toxin-A (BoNT-A) injections are administered to children with bilateral spastic cerebral palsy (BCP) to reduce spasticity, improve walking and functional mobility, and delay the need for orthopaedic surgery. Gait quality is clinically assessed following BoNT-A with 2D video gait assessments (2DVGA) using the Edinburgh Visual Gait Score (EVGS). AIM To determine the effect of three consecutive treatment cycles of lower limb intramuscular BoNT-A injections on gait quality using the EVGS in children with BCP by retrospectively reviewing repeated 2DVGA measures. METHODS AND PROCEDURES Seventeen children with BCP and dynamic equinus (8 females and 9 males, age mean (SD), 4.0 (2.2) years, GMFCS I=2 and II=15) were included in the study after a retrospective audit of the records of the Queensland Children's Gait Laboratory (QCGL), Children's Health Queensland, Brisbane. The medical records of children who attended the QCGL between January 2001 and January 2016 were searched for eligibility. Children who had undertaken pre- and post-treatment 2DVGA for the first three lower limb BoNT-A treatment cycles (6 assessments) were reviewed using the EVGS. BoNT-A treatments were administered 7.7 (2.3) months apart and post-BoNT-A reviews occurred 12.6 (6.7) weeks after injection. Mixed-effects linear regression assessed the change from baseline to each subsequent assessment (p<0.05). OUTCOMES AND RESULTS EVGS reduced significantly by a mean of 2.4 points from pre- to post-BoNT-A in the first treatment cycle (p=0.001). Compared to baseline, mean total EVGS reduced significantly during the second (pre-BoNT-A -1.7 (p=0.020), post BoNT-A -2.8 (p<0.001)) and third (pre-BoNT-A -2.6 (p=0.001), post BoNT-A -2.4 (p=0.002)) treatment cycles. There was no difference in EVGS between post-BoNT-A in the first treatment cycle and scores for the second and third treatment cycles. CONCLUSIONS AND IMPLICATIONS Improvements in gait quality were statistically significant, but did not reach the EVGS smallest real difference value of 4 points. Repeated lower limb intramuscular BoNT-A injections to improve gait quality in children with BCP should be reconsidered.
Collapse
Affiliation(s)
- Felicity A Read
- Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Brisbane, Australia.
| | - Roslyn N Boyd
- Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Brisbane, Australia
| | - Lee A Barber
- Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Brisbane, Australia
| |
Collapse
|
38
|
Efficacy of Repeated Botulinum Toxin Type A Injections for Spastic Equinus in Children with Cerebral Palsy-A Secondary Analysis of the Randomized Clinical Trial. Toxins (Basel) 2017; 9:toxins9080253. [PMID: 28825663 PMCID: PMC5577587 DOI: 10.3390/toxins9080253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/08/2017] [Accepted: 08/18/2017] [Indexed: 11/16/2022] Open
Abstract
Botulinum toxin A is considered an important tool to control spasticity in children with cerebral palsy. Several factors are known to affect the efficacy of botulinum toxin, such as dosage, appropriate muscle selection and application, age, and accompanying therapy. A multicenter, double-blind, randomized, prospective phase III clinical trial of botulinum toxin A for the treatment of dynamic equinus in 144 children with cerebral palsy was performed to compare the efficacies of letibotulinumtoxin A and onabotulinumtoxin A. Secondary analyses were performed to evaluate factors that affected the outcome, focusing on the number of times injections were repeated. Effectiveness was defined as a change of 2 or more in the physician’s rating scale. Multivariate regression analyses were performed with multiple variables. The first injection of botulinum toxin A significantly improved D subscale of Gross Motor Function Measure-88 scores at 3 months compared to repeated injections (p < 0.05). After 6 months, patients who had one injection or none before the study showed significantly better outcomes than those who had more than one injection in terms of observational gait scores.
Collapse
|
39
|
Lacroix-Desmazes S, Mouly S, Popoff MR, Colosimo C. Systematic analysis of botulinum neurotoxin type A immunogenicity in clinical studies. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.baga.2017.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|