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Klein C, Gouron R, Barbier V. Effects of botulinum toxin injections in the upper limbs of children with cerebral palsy: A systematic review of the literature. Orthop Traumatol Surg Res 2024; 110:103578. [PMID: 36754169 DOI: 10.1016/j.otsr.2023.103578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/20/2022] [Accepted: 11/03/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Spasticity is a common motor disorder in children with cerebral palsy (CP). Upper limb CP impairment has a significant negative impact on daily activities. Botulinum toxin (BTX-A) injections are widely used to reduce spasticity, but their effectiveness is not well-defined. We performed a systematic review of literature to answer questions about the effectiveness of BTX-A injections in the upper limb in children with CP. METHODS A systematic review of literature was conducted according to PRISMA guidelines. Eligible studies were randomized controlled trials with a high level of evidence on BTX-A upper limb injections in children. The outcomes analyzed included the study population, spasticity, quality of movement, activity limitations, quality of life, pain, appearance and side effects. RESULTS A total of 24 studies were included. The number of patients included was 1358 with a mean age between 3 and 11years. Improvement after BTX-A injection compared to the control group was observed for spasticity (n=10/19 studies), bimanual activities (Assisting Hand Assessment) (n=3/7), activity limitations (n=6/11), pain (n=2/2) and appearance (n=2/2). No study found an improvement in quality of life. Side effects were described in 16 studies and were moderate in all cases. CONCLUSION This review of literature showed that BTX-A injections can improve spasticity and particularly activity limitations when reasonable objectives are established. LEVEL OF EVIDENCE IV, systematic review.
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Affiliation(s)
- Céline Klein
- Service de chirurgie orthopédique pédiatrique, CHU Amiens-Picardie, Amiens, France; Laboratoire MP3CV, centre de recherche universitaire en santé, CHU Amiens-Picardie, université Picardie Jules-Verne, Amiens, France.
| | - Richard Gouron
- Service de chirurgie orthopédique pédiatrique, CHU Amiens-Picardie, Amiens, France; Laboratoire MP3CV, centre de recherche universitaire en santé, CHU Amiens-Picardie, université Picardie Jules-Verne, Amiens, France
| | - Vincent Barbier
- Laboratoire MP3CV, centre de recherche universitaire en santé, CHU Amiens-Picardie, université Picardie Jules-Verne, Amiens, France; Service de médecine physique et de réadaptation pédiatrique, CHU Amiens-Picardie, Amiens, France
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Bingol H, Kerem Gunel M, Alkan H. The Efficacy of Two Models of Intensive Upper Limb Training on Health-Related Quality of Life in Children with Hemiplegic Cerebral Palsy Mainstreamed in Regular Schools: A Double-Blinded, Randomized Controlled Trial. Physiother Theory Pract 2023; 39:10-25. [PMID: 34743663 DOI: 10.1080/09593985.2021.1999355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Children with hemiplegic cerebral palsy (CP) are at risk of reduced upper limb function and poorer quality of life than their typically developing peers. Although upper limb impairments have potential negative impact on the health-related quality of life (HRQOL) in children with hemiplegic CP, the efficacy of upper limb rehabilitation approaches aiming to improve upper limb impairments on HRQOL has not been adequately investigated. OBJECTIVE This study compares the efficacy of two modes of activity-based upper limb rehabilitation (modified constraint-induced movement therapy [mCIMT] and bimanual training [BIM]) on HRQOL outcomes in children with hemiplegic CP mainstreamed in regular schools. METHODS Thirty children with hemiplegic CP aged between 7 and 11 years (mean age 8.53 ± 1.54 years) who had functional ability levels of I-III according to the Manual Ability Classification System (MACS), Gross Motor Classification System (GMFCS), and Communication Function Classification System (CFCS) were randomly assigned to receive mCIMT or BIM training. Result: Both mCIMT and BIM yielded statistically significant improvements in all HRQOL domains immediately after the 10-week interventions (P < .001), which were retained at 16 weeks. CONCLUSION While there were some differences in the intervention effects, both of these upper limb rehabilitation approaches based on intensive unimanual or bimanual activity may be beneficial for improving perceived life satisfaction related to physical activity, general mood, family, friends, and school among children with hemiplegic CP mainstreamed in regular schools.
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Affiliation(s)
- Hasan Bingol
- Department of Therapy and Rehabilitation, Vocational School of Health Services, Mus Alparslan University, 49250-Güzeltepe/Mus, Turkey.,Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Hacettepe University, 06100-Samanpazarı/Ankara, Turkey
| | - Mintaze Kerem Gunel
- Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Hacettepe University, 06100-Samanpazarı/Ankara, Turkey
| | - Halil Alkan
- Department of Physiotherapy and Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, 06100-Samanpazarı/Ankara, Turkey.,Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Mus Alparslan University, 49250-Güzeltepe/Mus, Turkey
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Sporns PB, Fullerton HJ, Lee S, Kirton A, Wildgruber M. Current treatment for childhood arterial ischaemic stroke. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:825-836. [PMID: 34331864 DOI: 10.1016/s2352-4642(21)00167-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Paediatric arterial ischaemic stroke is an important cause of neurological morbidity in children, with consequences including motor disorders, intellectual impairment, and epilepsy. The causes of paediatric arterial ischaemic stroke are unique compared with those associated with stroke in adulthood. The past decade has seen substantial advances in paediatric stroke research and clinical care, but many unanswered questions and controversies remain. Shortage of prospective evidence for the use of recanalisation therapies in patients with paediatric stroke has resulted in little standardisation of disease management. Substantial time delays in diagnosis and treatment continue to challenge best possible care. In this Review, we highlight on some of the most pressing and productive aspects of research in the treatment of arterial ischaemic stroke in children, including epidemiology and cause, rehabilitation, secondary stroke prevention, and treatment updates focusing on advances in hyperacute therapies such as intravenous thrombolysis, mechanical thrombectomy, and critical care. Finally, we provide a future perspective for improving outcomes and quality of life for affected children and their families.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Weill Institute of Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam Kirton
- Department of Pediatrics and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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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.
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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
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Santos CA, Franco de Moura RC, Lazzari RD, Dumont AJL, Braun LAF, Oliveira CS. Upper limb function evaluation scales for individuals with cerebral palsy: a systematic review. J Phys Ther Sci 2015; 27:1617-20. [PMID: 26157275 PMCID: PMC4483453 DOI: 10.1589/jpts.27.1617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/11/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The aim of the present study was to perform a systematic review of the literature on the scales and methods most often used for the evaluation of upper limb function in individuals with cerebral palsy. [Materials and Methods] Searches were conducted in the Medline, PEDro, Lilacs, Scielo, and PubMed databases. The following inclusion criteria were used for the selection of articles: randomized controlled study, evaluation of upper limb function in individuals with cerebral palsy, and publication between 2006 and 2014. The methodological quality of the articles was evaluated using the PEDro evidence scale. [Results] Five articles met the inclusion criteria and achieved 6 points or higher on the PEDro scale of methodological quality. [Conclusion] The studies analyzed used different evaluation scales, but no consensus has been reached thus far on which scale is the most appropriate. Thus, further studies are needed to establish an adequate method for the evaluation of upper limb function in individuals with cerebral palsy.
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Nikaina I, Papavasiliou A. Potential of Botulinum toxin A to treat upper extremity spasticity in children with cerebral palsy. TOXIN REV 2014. [DOI: 10.3109/15569543.2014.896020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sakzewski L, Carlon S, Shields N, Ziviani J, Ware RS, Boyd RN. Impact of intensive upper limb rehabilitation on quality of life: a randomized trial in children with unilateral cerebral palsy. Dev Med Child Neurol 2012; 54:415-23. [PMID: 22429002 DOI: 10.1111/j.1469-8749.2012.04272.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to determine whether constraint-induced movement therapy is more effective than bimanual training in improving the quality of life of children with unilateral cerebral palsy (CP). METHOD Sixty-three children (mean age 10y 2mo [SD 2y 6mo]; 33 males, 30 females) with CP of the spastic motor type (n=59) or with spasticity and dystonia (n=4) were randomly allocated to two groups. The children were assessed as Manual Ability Classification System level I (n=16), II (n=46), or III (n=1). Each group received 6 hours of daily intervention (either constraint-induced movement therapy [CIMT] or bimanual training [BIM]) for 10 days over a 2-week period (total intervention time 60h). Children aged 9 years and older completed the Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL-Child) and those aged 8 years and older completed the KIDSCREEN-52. All parents completed proxy versions of each measure. Assessments were made at baseline and at 3, 26, and 52 weeks after the end of the intervention. RESULTS Thirty-five children completed the CPQOL-Child and 41 completed the KIDSCREEN-52. No changes in social or emotional well-being were reported by children in either group. Children and parents from both groups reported a significant improvement in their or their child's feelings about functioning as well as participation and physical health on the CPQOL-Child. The parents of children receiving CIMT reported positive and sustained changes in their child's social well-being (CPQOL-Child). The CIMT group showed significant improvements in physical well-being, psychological well-being, and moods and emotions (KIDSCREEN-52) at 3 weeks post intervention, which were maintained over the study period. INTERPRETATION Intensive goal-directed upper limb training programmes using either CIMT or BIM achieved domain-specific changes in quality of life relating to feelings about functioning and participation and physical health. A condition-specific quality of life compared with a generic measure may be better able to detect changes in quality of life in children with unilateral CP.
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Affiliation(s)
- Leanne Sakzewski
- Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Brisbane, QLD, Australia.
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Coutinho dos Santos LH, Bufara Rodrigues DC, Simões de Assis TR, Bruck I. Effective results with botulinum toxin in cerebral palsy. Pediatr Neurol 2011; 44:357-63. [PMID: 21481744 DOI: 10.1016/j.pediatrneurol.2010.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
Abstract
This study evaluated the improvement in clinical measures and quality of life (QOL) among patients with cerebral palsy treated with botulinum toxin type A. Fifty-seven parents of cerebral palsy patients who used botulinum toxin during the time of the study were enrolled. The QOL questionnaires included the following: Child Caregiver Questionnaire, Pediatrics Outcomes Data Collection Instrument, and clinical evaluations. The questionnaires were administered before the first use of botulinum toxin and approximately 1 year later, a mean interval of 13.8 months. Treatment resulted in clinical improvement in tone, upper limb function, and Gross Motor Function Classification System score. Better outcomes were observed in patients younger than 6.5 years. QOL questionnaires revealed a tendency toward improvement in the comfort dimension of the Child Caregiver Questionnaire as well as in the upper extremities and physical functions, transfers and basic mobility, and global function and symptom of the Pediatrics Outcomes Data Collection Instrument. The QOL measures correlated with clinical evaluations. Patients with low cognitive ability and refractory epilepsy had the worst results. Children and adolescents have reduced spasticity and experience good results in the clinical measurements and in QOL after treatment with botulinum toxin.
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Affiliation(s)
- Lúcia H Coutinho dos Santos
- Discipline of Pediatric Neurology, Pediatric Department, Federal University of Paraná, Curitiba, Paraná, Brazil.
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Hoare BJ, Wallen MA, Imms C, Villanueva E, Rawicki HB, Carey L. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database Syst Rev 2010; 2010:CD003469. [PMID: 20091546 PMCID: PMC7154577 DOI: 10.1002/14651858.cd003469.pub4] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbance that occurred in the developing fetal or infant brain" (Rosenbaum 2007, p.9). The spastic motor type is the most common form of CP. Therapeutic management may include splinting/casting, passive stretching, facilitation of posture/movement, spasticity-reducing medication and surgery. Botulinum toxin-A (BoNT-A) is now used as an adjunct to these techniques in an attempt to reduce spasticity, improve range of movement and function. OBJECTIVES To assess the effectiveness of injections of BoNT-A or BoNT-A and occupational therapy in the treatment of the upper limb in children with CP. SEARCH STRATEGY We searched the Cochrane Controlled Trials Register/CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (1966 to August Week 1 2008), EMBASE (1980 to 2008 Week 28) and CINAHL (1982 to August Week 1 2008). SELECTION CRITERIA All randomised controlled trials (RCTs) comparing BoNT-A injection or BoNT-A injection and occupational therapy in the upper limb(s) with other types of treatment (including no treatment or placebo) in children with CP. DATA COLLECTION AND ANALYSIS Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity and rated for quality using the PEDro scale. Data were extracted and entered into RevMan 5.0.15. MAIN RESULTS Ten trials met the inclusion criteria. PEDro quality ratings ranged from 6/10 to 10/10. Concentration of BoNT-A ranged from 50U/1.0ml to 200U/1.0ml saline with doses of 0.5U to 16U/kg body weight and total doses of 220 to 410 Units (Botox(R)).A combination of BoNT-A and occupational therapy is more effective than occupational therapy alone in reducing impairment, improving activity level outcomes and goal achievement, but not for improving quality of life or perceived self-competence. When compared with placebo or no treatment, there is moderate evidence that BoNT-A alone is not effective. AUTHORS' CONCLUSIONS This systematic review found high level evidence supporting the use of BoNT-A as an adjunct to managing the upper limb in children with spastic CP. BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy.Further research is essential to identify children most likely to respond to BoNT-A injections, monitor longitudinal outcomes, determine timing and effect of repeated injections and the most effective dosage, dilution and volume schedules. The most effective adjunct therapies including frequency and intensity of delivery also requires investigation.
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Affiliation(s)
- Brian J Hoare
- La Trobe University, Victorian Paediatric Rehabilitation Service, Monash Medical CentreSchool of Occupational Therapy246 Clayton RoadClaytonVictoriaAustralia3086
| | - Margaret A Wallen
- The Children's Hospital at WestmeadOccupational TherapyLocked Bag 4001WestmeadNSWAustralia2145
| | - Christine Imms
- LaTrobe University, Murdoch Children's Research Institute, Royal Children's HosptialSchool of Occupational TherapyLa Trobe UniversityMelbourneVictoriaAustralia3086
| | - Elmer Villanueva
- Monash UniversityGippsland Medical SchoolNorthways RoadChurchillVictoriaAustralia3842
| | - Hyam Barry Rawicki
- Monash Medical CentreVictorian Paediatric Rehabilitation Service246 Clayton RoadClaytonVictoriaAustralia3168
| | - Leeanne Carey
- School of Occupational Therapy, LaTrobe UniversityDivision of Neurorehabilitation and Recovery, National Stroke Research Institute, Florey Neuroscience Institutes andLevel 2, Neurosciences Bldg, Austin Health, Repatriation Campus300 Waterdale Road, Heidleberg HeightsMelbourneVictoriaAustralia3081
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Idrovo AJ, Albavera-Hernández C, Rodríguez JM. Letter to the editor on 'Safety of botulinum toxin type A among children with spasticity secondary to cerebral palsy: a systematic review of randomized clinical trials'. Clin Rehabil 2009; 23:862-3. [PMID: 19713401 DOI: 10.1177/0269215509339882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Spasticity and other forms of muscle overactivity caused by cerebral palsy may impair function or ease of care or may cause discomfort or poor body image. The treatment program for a child with spasticity may include allied health therapy, exercise, casting, constraint-induced therapy, oral medications, chemodenervation, intrathecal baclofen, selective dorsal rhizotomy, and orthopedic surgery. Techniques may be combined for greater efficacy and better tailoring to the needs of the child. This article provides an overview of each approach, with a review of significant research findings in support of each.
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Affiliation(s)
- Ann Tilton
- Department of Neurology, Louisiana State University Health and Sciences Center, New Orleans, LA 70118, USA.
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