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Klaewkasikum K, Patathong T, Woratanarat P, Woratanarat T, Thadanipon K, Rattanasiri S, Thakkinstian A. Efficacy of conservative treatment for spastic cerebral palsy children with equinus gait: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:411. [PMID: 36076293 PMCID: PMC9461190 DOI: 10.1186/s13018-022-03301-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion. Methods Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I2 was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI). Results From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I2 = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I2 = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I2 = 87%). Conclusion BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03301-3.
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Affiliation(s)
- Krongkaew Klaewkasikum
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Tanyaporn Patathong
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Patarawan Woratanarat
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
| | - Thira Woratanarat
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Kunlawat Thadanipon
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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Milne N, Miao M, Beattie E. The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis. BMC Pediatr 2020; 20:324. [PMID: 32615954 PMCID: PMC7330971 DOI: 10.1186/s12887-020-02122-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background Lower limb serial casting is commonly used therapeutically in paediatric clinical practice with some evidence to support its efficacy. This systematic review aimed to determine the effects of serial casting in isolation or combination with other therapies for the management of lower limb dysfunction in children with Cerebral Palsy (CP). Methods A systematic literature search was conducted in February 2019 across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using key terms ‘Cerebral Palsy’ and ‘serial casting’ and associated synonyms. A meta-synthesis and meta-analysis were undertaken when sufficient results were available showing the effect of serial casting on functional outcomes including: Ankle range of motion; neurological measures of hypertonicity and spasticity, functional gait measures and; gross motor function. Results Twenty-five articles from 3219 possible citations were included. Serial casting was found to be effective for: Improving ankle dorsiflexion (DF) passive range of motion (PROM) in the immediate to short-term, decreasing hypertonicity measured by Modified Ashworth Scale (MAS) in the short-term and, enhancing functional gait outcomes in the mid-term. Serial casting with or without botulinum toxin type-A (BTX-A) did not significantly affect gross motor capacity measured by Gross Motor Function Measure (GMFM). Serial casting with pharmacological intervention achieved significantly more DF PROM than serial casting alone (MD − 3.19 degrees; 95% CI − 5.76 to − 0.62; P = 0.01; I2 = 0%), however the clinical importance of improving ankle DF PROM by an additional three degrees remains unclear. Conclusions Lower limb serial casting, improves several outcomes relevant to lower limb function supporting its clinical use for improving DF PROM, reducing hypertonicity and improving gait in children with CP. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes such as gross motor function in children with CP. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.
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Affiliation(s)
- Nikki Milne
- Physiotherapy Program, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4229, Australia. .,Department of Physiotherapy, Bond Institute of Health and Sport, Bond University, Gold Coast, Australia.
| | - Michelle Miao
- Physiotherapy Program, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4229, Australia
| | - Emma Beattie
- Physiotherapy Program, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4229, Australia
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Kalkman BM, Bar-On L, O'Brien TD, Maganaris CN. Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome? Front Physiol 2020; 11:131. [PMID: 32153428 PMCID: PMC7047287 DOI: 10.3389/fphys.2020.00131] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/06/2020] [Indexed: 12/27/2022] Open
Abstract
Hyper-resistance at the joint is one of the most common symptoms in children with cerebral palsy (CP). Alterations to the structure and mechanical properties of the musculoskeletal system, such as a decreased muscle length and an increased joint stiffness are typically managed conservatively, by means of physiotherapy involving stretching exercises. However, the effectiveness of stretching-based interventions for improving function is poor. This may be due to the behavior of a spastic muscle during stretch, which is poorly understood. The main aim of this paper is to provide a mechanistic explanation as to why the effectiveness of stretching is limited in children with CP and consider clinically relevant means by which this shortcoming can be tackled. To do this, we review the current literature regarding muscle and tendon plasticity in response to stretching in children with CP. First, we discuss how muscle and tendon interact based on their morphology and mechanical properties to provide a certain range of motion at the joint. We then consider the effect of traditional stretching exercises on these muscle and tendon properties. Finally, we examine possible strategies to increase the effectiveness of stretching therapies and we highlight areas of further research that have the potential to improve the outcome of non-invasive interventions in children with cerebral palsy.
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Affiliation(s)
- Barbara M Kalkman
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Lynn Bar-On
- Department of Rehabilitation Medicine, VC University Medical Center Amsterdam, Amsterdam, Netherlands
| | - Thomas D O'Brien
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Constantinos N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
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Lorentzen J, Willerslev-Olsen M, Hüche Larsen H, Farmer SF, Nielsen JB. Maturation of feedforward toe walking motor program is impaired in children with cerebral palsy. Brain 2020; 142:526-541. [PMID: 30726881 DOI: 10.1093/brain/awz002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/02/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022] Open
Abstract
Voluntary toe walking in adults is characterized by feedforward control of ankle muscles in order to ensure optimal stability of the ankle joint at ground impact. Toe walking is frequently observed in children with cerebral palsy, but the mechanisms involved have not been clarified. Here, we investigated maturation of voluntary toe walking in typically-developing children and typically-developed adults and compared it to involuntary toe walking in children with cerebral palsy. Twenty-eight children with cerebral palsy (age 3-14 years), 24 typically-developing children (age 2-14 years) and 15 adults (mean age 30.7 years) participated in the study. EMG activity was measured from the tibialis anterior and soleus muscles together with knee and ankle joint position during treadmill walking. In typically-developed adults, low step-to-step variability of the drop of the heel after ground impact was correlated with low tibialis anterior and high soleus EMG with no significant coupling between the antagonist muscle EMGs. Typically-developing children showed a significant age-related decline in EMG amplitude reaching an adult level at 10-12 years of age. The youngest typically-developing children showed a broad peak EMG-EMG synchronization (>100 ms) associated with large 5-15 Hz coherence between antagonist muscle activities. EMG coherence declined with age and at the age of 10-12 years no correlation was observed similar to adults. This reduction in coherence was closely related to improved step-to-step stability of the ankle joint position. Children with cerebral palsy generally showed lower EMG levels than typically-developing children and larger step-to-step variability in ankle joint position. In contrast to typically-developing children, children with cerebral palsy showed no age-related decline in tibialis anterior EMG amplitude. Motor unit synchronization and 5-15 Hz coherence between antagonist EMGs was observed more frequently in children with cerebral palsy when compared to typically-developing children and in contrast to typically-developing participants there was no age-related decline. We conclude that typically-developing children develop mature feedforward control of ankle muscle activity as they age, such that at age 10-12 years there is little agonist-antagonist muscle co-contraction around the time of foot-ground contact during toe walking. Children with cerebral palsy, in contrast, continue to co-contract agonist and antagonist ankle muscles when toe walking. We speculate that children with cerebral palsy maintain a co-contraction activation pattern when toe walking due to weak muscles and insufficient motor and sensory signalling necessary for optimization of feedforward motor programs. These findings are important for understanding of the pathophysiology and treatment of toe walking.
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Affiliation(s)
- Jakob Lorentzen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
| | - Maria Willerslev-Olsen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
| | | | - Simon Francis Farmer
- Department of Clinical and Movement Neuroscience, Institute of Neurology, University College London, London, UK.,Department of Clinical Neurology, National Hospital for Neurology and Neurosurgery, UK
| | - Jens Bo Nielsen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
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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.
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6
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Adjunct therapies to improve outcomes after botulinum toxin injection in children: A systematic review. Ann Phys Rehabil Med 2019; 62:283-290. [DOI: 10.1016/j.rehab.2018.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/28/2018] [Accepted: 06/30/2018] [Indexed: 11/17/2022]
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Kelly B, MacKay-Lyons M, Berryman S, Hyndman J, Wood E. Casting Protocols Following BoNT-A Injections to Treat Spastic Hypertonia of the Triceps Surae in Children with Cerebral Palsy and Equinus Gait: A Randomized Controlled Trial. Phys Occup Ther Pediatr 2019; 39:77-93. [PMID: 29771161 DOI: 10.1080/01942638.2018.1471015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM To study the effects of single versus serial casting post-Botulinum toxin A (BoNT-A) injections on hypoextensibility of triceps surae in children, 2-7 years old, with cerebral palsy and equinus gait. METHODS A randomized, stratified, parallel, two-group trial was conducted at a pediatric health center with assessments at baseline, precast, postcast and, 1-, 2-, and 6-month follow-ups. One week following BoNT-A injections into triceps surae muscle, a single below-knee cast (n = 10) or 3 serial casts (n = 10) were applied for 3 weeks. Primary outcome measure was the Modified Tardieu Scale (MTS), secondary outcome measures were Modified Ashworth Scale (MAS), GAITRite™, Gross Motor Function Measure-66 (GMFM-66), and Pediatric Evaluation of Disability Inventory (PEDI). RESULTS Significant effects of time, but not group-by-time, were found for MTS R1 (P < 0.001), MTS R2 (P < 0.001), MAS (P = 0.001), GMFM-66 (P = 0.002), and PEDI (P < 0.001-0.009). One participant who received a single cast did not complete the 6-month assessment. CONCLUSIONS Magnitudes of improvements were similar using single or serial casting. If these findings are corroborated in a larger scale study, the recommendation of a single cast may be appropriate due to its greater convenience for families and clinicians.
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Affiliation(s)
- Barbara Kelly
- a School of Physiotherapy , Dalhousie University , Halifax, Nova Scotia , Canada and IWK Health Centre Halifax , Nova Scotia , Canada
| | - Marilyn MacKay-Lyons
- b School of Physiotherapy , Dalhousie University , Halifax, Nova Scotia , Canada
| | | | - Joe Hyndman
- d IWK Health Centre and Faculty of Medicine , Dalhousie University , Halifax, Nova Scotia , Canada
| | - Ellen Wood
- d IWK Health Centre and Faculty of Medicine , Dalhousie University , Halifax, Nova Scotia , Canada
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Martín Lorenzo T, Rocon E, Martínez Caballero I, Ramírez Barragán A, Lerma Lara S. Prolonged stretching of the ankle plantarflexors elicits muscle-tendon adaptations relevant to ankle gait kinetics in children with spastic cerebral palsy. Med Hypotheses 2017; 109:65-69. [DOI: 10.1016/j.mehy.2017.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 12/21/2022]
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Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev 2017; 1:CD007455. [PMID: 28146605 PMCID: PMC6464268 DOI: 10.1002/14651858.cd007455.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review. OBJECTIVES The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events. SEARCH METHODS In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries. SELECTION CRITERIA We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE. MAIN RESULTS Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds' phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data. AUTHORS' CONCLUSIONS There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.
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Affiliation(s)
- Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchRoyal North Shore HospitalSt LeonardsNSWAustralia2065
| | - Owen M Katalinic
- Telstra HealthEmerging Systems18/9 Hoyle AvenueCastle HillNSWAustralia2154
| | - Robert D Herbert
- Neuroscience Research AustraliaBarker StreetRandwickSydneyAustralia2031
| | - Anne M Moseley
- The George Institute for Global Health, Sydney Medical School, The University of SydneyPO Box M201Missenden RdSydneyNSWAustralia2050
| | - Natasha A Lannin
- La Trobe UniversityOccupational Therapy, Department of Community and Clinical Allied Health, School of Allied Health, College of Science, Health and EngineeringMelbourneVictoriaAustralia
| | - Karl Schurr
- Bankstown HospitalPhysiotherapy DepartmentLocked Bag 1600BankstownNSWAustralia2200
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Kinney MC, Dayanidhi S, Dykstra PB, McCarthy JJ, Peterson CA, Lieber RL. Reduced skeletal muscle satellite cell number alters muscle morphology after chronic stretch but allows limited serial sarcomere addition. Muscle Nerve 2016; 55:384-392. [PMID: 27343167 DOI: 10.1002/mus.25227] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 06/14/2016] [Accepted: 06/16/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Muscles add sarcomeres in response to stretch, presumably to maintain optimal sarcomere length. Clinical evidence from patients with cerebral palsy, who have both decreased serial sarcomere number and reduced satellite cells (SCs), suggests a hypothesis that SCs may be involved in sarcomere addition. METHODS A transgenic Pax7-DTA mouse model underwent conditional SC depletion, and their soleii were then stretch-immobilized to assess the capacity for sarcomere addition. Muscle architecture, morphology, and extracellular matrix (ECM) changes were also evaluated. RESULTS Mice in the SC-reduced group achieved normal serial sarcomere addition in response to stretch. However, muscle fiber cross-sectional area was significantly smaller and was associated with hypertrophic ECM changes, consistent with fibrosis. CONCLUSIONS While a reduced SC population does not hinder serial sarcomere addition, SCs play a role in muscle adaptation to chronic stretch that involves maintenance of both fiber cross-sectional area and ECM structure. Muscle Nerve 55: 384-392, 2017.
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Affiliation(s)
- Matthew C Kinney
- Department of Orthopaedic Surgery, University of California, San Diego, California, USA
| | - Sudarshan Dayanidhi
- Department of Orthopaedic Surgery, University of California, San Diego, California, USA.,Department of Veterans Affairs Medical Center, San Diego, California, USA
| | - Peter B Dykstra
- Department of Bioengineering, University of California, San Diego, California, USA
| | - John J McCarthy
- Department of Physiology, University of Kentucky, Lexington, Kentucky, USA
| | - Charlotte A Peterson
- Department of Rehabilitation Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Richard L Lieber
- Department of Orthopaedic Surgery, University of California, San Diego, California, USA.,Department of Veterans Affairs Medical Center, San Diego, California, USA.,Department of Bioengineering, University of California, San Diego, California, USA
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Effectiveness of Stretch Interventions for Children With Neuromuscular Disabilities: Evidence-Based Recommendations. Pediatr Phys Ther 2016; 28:262-75. [PMID: 27341572 DOI: 10.1097/pep.0000000000000269] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine whether casting, orthoses, stretching, or supported standing programs are effective in improving or maintaining body functions and structures, activity, or participation in children with neuromuscular disabilities. METHODS A systematic review was conducted using 6 electronic databases to identify Level 1 and 2 studies investigating stretch interventions for children aged 0 to 19 years with neuromuscular disabilities. Interventions were coded using the International Classification of Function and rated with Grading of Recommendation Assessment, Development and Evaluation, the Oxford Levels of Evidence, and the Evidence Alert Traffic Light System. RESULTS Sixteen studies evaluated the effectiveness of stretch interventions. Low-grade evidence supports casting temporarily increasing ankle range of motion, orthoses improving gait parameters while they are worn, and supported standing programs improving bone mineral density. CONCLUSION There is limited evidence suggesting stretch interventions benefit body functions and structures. There is inconclusive evidence to support or refute stretching interventions for preventing contractures or impacting a child's activity or participation. TRIAL REGISTRATION Prospero CRD42014013807.
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Kurenkov AL, Klochkova OA, Zmanovskaya VA, Falkovskiy IV, Kenis VM, Vladykina LN, Krasavina DA, Nosko AS, Rychkova LV, Karimova KM, Bursagova BI, Namazova-baranova LS, Mamedyarov AM, Kuzenkova LM, Dontzov OG, Ryzhenkov MA, Butorina MN, Pavlova OL, Harlamova NN, Dankov DM, Levitina EV, Popkov DA, Ryabykh SO, Medvedeva SN, Gubina EB, Agranovich OV, Kiseleva TI, Vasileva ON, Zykov VP, Mihnovich VI, Belogorova ТА. The First Russian Consensus on the Multilevel Abobotulinumtoxin A Injections in Spastic Forms of Cerebral Palsy. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:121-130. [DOI: 10.17116/jnevro2016116111121-130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tustin K, Patel A. A Critical Evaluation of the Updated Evidence for Casting for Equinus Deformity in Children with Cerebral Palsy. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2015; 22. [DOI: 10.1002/pri.1646] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/15/2015] [Accepted: 06/12/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Kylee Tustin
- Complex Motor Disorders Service, Guy's and St Thomas' NHS Foundation Trust; Evelina London Children's Hospital; 6th Floor Sky, Westminster Bridge Road London SE1 7EH UK
| | - Anita Patel
- Paediatric Neurosciences, Guy's and St Thomas' NHS Foundation Trust; Evelina London Children's Hospital; 6th Floor Sky, Westminster Bridge Road London SE1 7EH UK
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14
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Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013; 55:885-910. [PMID: 23962350 DOI: 10.1111/dmcn.12246] [Citation(s) in RCA: 787] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 02/07/2023]
Abstract
AIM The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP). METHOD This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health. RESULTS Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red). INTERPRETATION Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist.
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Affiliation(s)
- Iona Novak
- Cerebral Palsy Alliance, Sydney, Australia; University of Notre Dame Australia, Sydney, Australia
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15
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Effgen SK, McEwen IR. Review of selected physical therapy interventions for school age children with disabilities. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/174328808x309287] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Treating spastic equinus foot from cerebral palsy with botulinum toxin type A: what factors influence the results?: an analysis of 189 consecutive cases. Am J Phys Med Rehabil 2011; 90:554-63. [PMID: 21765274 DOI: 10.1097/phm.0b013e31821f6c40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the variables that improve spastic equinus foot caused by cerebral palsy when treated with botulinum toxin type A. DESIGN We reviewed all patients treated for spastic equinus foot using botulinum toxin type A (Botox) in the triceps suralis during a 3 1/2-yr period and analyzed the results after the first injection. There were 117 patients (72 diplegic and 45 hemiplegic patients) and a total of 189 triceps suralis treated. Variables analyzed included age, total dose per session, total dose per kilogram for each session, total dose per triceps, triceps dose per kilogram, type of cerebral palsy, cognitive level, botulinum toxin dilution, and physiotherapy. Assessments of efficacy were done using a Global Assessment Scale rated independently by parents, therapists, and a neurologist; the Modified Ashworth Scale; and the Modified Physician Rating Koman scale. RESULTS Improvement was observed in all scales (P < 0.001). The change of foot position during walking was the best parameter for measuring improvement. There was correlation between the grade of improvement and the dose per kilogram for each triceps suralis (P < 0.001). Patient age was inversely correlated with improvement (P = 0.043). Diplegic and hemiplegic patients improved similarly, but the hemiplegic patients required higher doses for each muscle (P < 0.001). The most effective dose for diplegic patients was 3-4 IU/kg for each triceps, compared with 4-6 IU/kg for hemiplegic patients. Different dilutions of Botox (100, 50, and 40 U/ml) resulted in similar outcomes. No better results were achieved when 2-3 sessions/wk of physiotherapy was added to a daily program of exercises at home to enhance foot dorsiflexion. CONCLUSIONS The dose per kilogram of Botox injected into triceps suralis and the patient age influence the results. The most effective dose is different between diplegic and hemiplegic patients. The concentration of botulinum toxin type A does not play a significant role in the outcome.
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Therapeutic use of botulinum toxin in neurorehabilitation. J Toxicol 2011; 2012:802893. [PMID: 21941544 PMCID: PMC3172973 DOI: 10.1155/2012/802893] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 06/28/2011] [Accepted: 07/13/2011] [Indexed: 12/14/2022] Open
Abstract
The botulinum toxins (BTX), type A and type B by blocking vesicle acetylcholine release at neuro-muscular and neuro-secretory junctions can result efficacious therapeutic agents for the treatment of numerous disorders in patients requiring neuro-rehabilitative intervention. Its use for the reduction of focal spasticity following stroke, brain injury, and cerebral palsy is provided. Although the reduction of spasticity is widely demonstrated with BTX type A injection, its impact on the improvement of dexterity and functional outcome remains controversial. The use of BTX for the rehabilitation of children with obstetrical brachial plexus palsy and in treating sialorrhea which can complicate the course of some severe neurological diseases such as amyotrophic lateral sclerosis and Parkinson's disease is also addressed. Adverse events and neutralizing antibodies formation after repeated BTX injections can occur. Since impaired neurological persons can have complex disabling feature, BTX treatment should be viewed as adjunct measure to other rehabilitative strategies that are based on the individual's residual ability and competence and targeted to achieve the best functional recovery. BTX therapy has high cost and transient effect, but its benefits outweigh these disadvantages. Future studies must clarify if this agent alone or adjunctive to other rehabilitative procedures works best on functional outcome.
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Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, O'Flaherty S, Graham HK. Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. Eur J Neurol 2011; 17 Suppl 2:9-37. [PMID: 20633177 DOI: 10.1111/j.1468-1331.2010.03126.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Botulinum neurotoxin type-A (BoNT-A) has been used in association with other interventions in the management of spasticity in children with cerebral palsy (CP) for almost two decades. This consensus statement is based on an extensive review of the literature by an invited international committee. The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention. Randomized clinical trials have been grouped into five areas of management, and the outcomes are presented as treatment recommendations. The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex, and therefore, a range of measures and the involvement of a multidisciplinary team is recommended. The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur, especially in children with more physical limitations (GMFCS V). The recommended dose levels are intermediate between previous consensus statements. The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP, and when combined with physiotherapy and the use of orthoses, these interventions may improve gait and goal attainment.
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Affiliation(s)
- S C Love
- Centre for Musculoskeletal Studies, University of Western Australia, Princess Margaret Hospital, Perth, Western Australia, Australia.
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Ryll U, Bastiaenen C, De Bie R, Staal B. Effects of leg muscle botulinum toxin A injections on walking in children with spasticity-related cerebral palsy: a systematic review. Dev Med Child Neurol 2011; 53:210-6. [PMID: 21291464 DOI: 10.1111/j.1469-8749.2010.03890.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To assess treatment effects of botulinum toxin type A (BoNT-A) on walking of children with leg spasticity due to cerebral palsy (CP) compared with usual care. METHOD We systematically searched the databases CINAHL, Cochrane, PEDro, EMBASE, and PubMed from July 1993 until July 2009 and additionally screened reference lists. Randomized controlled trials assessing functional outcomes on walking of children with CP were included. The intervention had to contain BoNT-A into the lower limb and be compared with usual care. The methodological quality and clinical relevance were independently assessed by two of the authors (UCR, CHGB). If statistical pooling was not feasible, we performed a best-evidence synthesis. RESULTS Eight trials were included. Trials comparing BoNT-A plus usual care or physiotherapy versus usual care or physiotherapy alone showed moderate evidence for functional outcomes at 2 to 6, 12, and 24 weeks follow-up in favour of BoNT-A. Studies comparing BoNT-A versus casting showed strong evidence for no difference in effects between these interventions. A limitation of our review was the exclusion of studies not published in English, Dutch, or German. The heterogeneity of the included studies, especially for outcome measures and follow-up assessments, prompted us to refrain from statistical pooling, which might also be considered a limitation. INTERPRETATION The use of BoNT-A with usual care or physiotherapy seems to improve walking of children with CP, but results should be appraised carefully owing to the limited quality of included trials.
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Affiliation(s)
- Ulrike Ryll
- Department of Epidemiology, Caphri Research Institute, Maastricht University, Maastricht, The Netherlands
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Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review. Phys Ther 2011; 91:11-24. [PMID: 21127166 DOI: 10.2522/ptj.20100265] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Contractures are a disabling complication of neurological conditions that are commonly managed with stretch. OBJECTIVE The purpose of this systematic review was to determine the effectiveness of stretch for the treatment and prevention of contractures. The review is part of a more-detailed Cochrane review. Only the results of the studies including patients with neurological conditions are reported here. DATA SOURCES Electronic searches were conducted in June 2010 in the following computerized databases: Cochrane CENTRAL Register of Controlled Trials, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, SCI-EXPANDED, and Physiotherapy Evidence Database (PEDro). STUDY ELIGIBILITY CRITERIA The review included randomized controlled trials and controlled clinical trials of stretch applied for the purposes of treating or preventing contractures in people with neurological conditions. STUDY APPRAISAL AND SYNTHESIS METHODS Two reviewers independently selected studies, extracted data, and assessed risk of bias. The primary outcome measures were joint mobility (range of motion) and quality of life. Secondary outcome measures were pain, spasticity, activity limitation, and participation restriction. Meta-analyses were conducted using random-effects models. RESULTS Twenty-five studies met the inclusion criteria. These studies provide moderate-quality evidence that stretch has a small immediate effect on joint mobility (mean difference=3°, 95% confidence interval [CI]=0° to 5°) and high-quality evidence that stretch has little or no short-term or long-term effects on joint mobility (mean difference=1° and 0°, respectively, 95% CI=0° to 3° and -2° to 2°, respectively). There is little or no effect of stretch on pain, spasticity, and activity limitation. LIMITATIONS No studies were retrieved that investigated the effects of stretch for longer than 6 months. CONCLUSION Regular stretch does not produce clinically important changes in joint mobility, pain, spasticity, or activity limitation in people with neurological conditions.
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Abstract
PURPOSE To evaluate the effect of serial casting in boys with Duchenne muscular dystrophy. METHODS Chart review of 9 patients with Duchenne muscular dystrophy, mean age 8.9 (±2.1) years. RESULTS Initial dorsiflexion -6.2° and -5.2° right and left, respectively. The mean improvement was 12° and 11.6° on the right and left (knee extended) and 7.7° and 8.7° on the right and left (knee flexed) or 2.7° and 3.9° per cast, respectively. Times to run 10 m, climb 4 steps, and get off the floor were unchanged. Correlations between range-of-motion change/cast and age were r = -0.86 right and r = -0.84 left. Three patients had delayed onset foot pain; one child had redness with symptom resolution in all cases. CONCLUSIONS Improvement in range of motion with the application of serial casting was found with no loss of function or speed despite the period of immobilization.
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Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev 2010:CD007455. [PMID: 20824861 DOI: 10.1002/14651858.cd007455.pub2] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Contractures are a common complication of neurological and musculoskeletal conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. OBJECTIVES To determine the effects of stretch on contractures in people with, or at risk of, contractures. SEARCH STRATEGY Electronic searches were conducted on CENTRAL, DARE, HTA (The Cochrane Library); MEDLINE; CINAHL; EMBASE; SCI-EXPANDED; and PEDro (April 2009). SELECTION CRITERIA Randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, and assessed risk of bias. The primary outcomes of interest were joint mobility and quality of life. The secondary outcomes were pain, spasticity, activity limitation and participation restriction. Outcomes were evaluated immediately after intervention, in the short term (one to seven days) and in the long term (> one week). Effects were expressed as mean differences or standardised mean differences with 95% confidence intervals (CI). Meta-analyses were conducted with a random-effects model. MAIN RESULTS Thirty-five studies with 1391 participants met the inclusion criteria. No study performed stretch for more than seven months. In people with neurological conditions, there was moderate to high quality evidence to indicate that stretch does not have clinically important immediate (mean difference 3 degrees ; 95% CI 0 to 7), short-term (mean difference 1 degrees ; 95% CI 0 to 3) or long-term (mean difference 0 degrees ; 95% CI -2 to 2) effects on joint mobility. The results were similar for people with non-neurological conditions. For all conditions, there is little or no effect of stretch on pain, spasticity, activity limitation, participation restriction or quality of life. AUTHORS' CONCLUSIONS Stretch does not have clinically important effects on joint mobility in people with, or at risk of, contractures if performed for less than seven months. The effects of stretch performed for periods longer than seven months have not been investigated.
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Affiliation(s)
- Owen M Katalinic
- Rehabilitation Studies Unit, Northern Clinical School, Sydney Medical School, The University of Sydney, PO Box 6, Ryde, NSW, Australia, 1680
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Placzek R, Siebold D, Funk JF. Development of treatment concepts for the use of botulinum toxin a in children with cerebral palsy. Toxins (Basel) 2010; 2:2258-71. [PMID: 22069684 PMCID: PMC3153296 DOI: 10.3390/toxins2092258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 08/24/2010] [Accepted: 08/26/2010] [Indexed: 11/16/2022] Open
Abstract
The treatment of children with cerebral palsy with Botulinum toxin A injections is well established, safe and effective. However, a standardized injection strategy is still missing and the used dosage has escalated over the years. In the recent past, the recommended dosages in Europe were, however, reduced due to a better understanding of the relationship between dosage, severe side effects and the kind of anesthesia used. To combine safety and efficacy, the trend tends to a lower dosage, but combined with a more specific selection of injected muscles. The treatment of these key-muscles takes into account the best support for motor development to attain each individual motor milestone.
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Affiliation(s)
- Richard Placzek
- Department of Paediatric Orthopaedics, Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany;
- Author to whom correspondence should be addressed; ; Tel.: +49-0-30-450-652247
| | - Dagmar Siebold
- Centre for physiotherapy and neurorehabilitation, Berlin, Germany;
| | - Julia F. Funk
- Department of Paediatric Orthopaedics, Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany;
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Park ES, Rha DW, Yoo JK, Kim SM, Chang WH, Song SH. Short-term effects of combined serial casting and botulinum toxin injection for spastic equinus in ambulatory children with cerebral palsy. Yonsei Med J 2010; 51:579-84. [PMID: 20499426 PMCID: PMC2880273 DOI: 10.3349/ymj.2010.51.4.579] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
PURPOSE The purpose of this paper is to test the hypothesis that combination therapy of serial cast and botulinum toxin type A (BTX-A) injection can further enhance the effects of a BTX-A injection in ambulant children with cerebral palsy (CP) who have an equinus foot. MATERIALS AND METHODS Children in group A (30 legs of 21 children) received a serial casting application after an injection of BTX-A, and children in group B (25 legs of 17 children) received only a BTX-A injection. Assessments were performed before the intervention and 1 month after the intervention. RESULTS After the intervention, there were significant improvements in tone, dynamic spasticity, and passive range of motion (ROM) in both groups. However, the changes were greater in group A than in group B. Dimension D (standing) in Gross Motor Function Measure (GMFM)-66 was significantly improved in group A but not in group B. On the other hand, there were no significant changes in dimension E (walking, running, jumping) in GMFM-66 in either group. CONCLUSION The results of our study suggest that a serial casting application after BTX-A injection can enhance the benefits of BTX-A injection in children with cerebral palsy.
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Affiliation(s)
- Eun Sook Park
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-wook Rha
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Ki Yoo
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Mi Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyuk Song
- Departments of Physical Medicine and Rehabilitation, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
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Koog YH, Min BI. Effects of botulinum toxin A on calf muscles in children with cerebral palsy: a systematic review. Clin Rehabil 2010; 24:685-700. [PMID: 20554641 DOI: 10.1177/0269215510367557] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the efficacy of botulinum toxin A injection for the management of spastic calf muscles in children with cerebral palsy. DATA SOURCES We reviewed all relevant literature indexed in MEDLINE, CINAHL, EMBASE, PEDro and the Cochrane Registered Trials, and also hand reviewed abstracts. METHODS Eligible studies were randomized controlled trials that compared botulinum toxin A injection with any type of treatment or no treatment with identical conditions. We extracted data on calf muscle tone, passive ankle range of motion, gait speed, ankle kinematics and Gross Motor Function Measure, and assessed methodological qualities. RESULTS Fifteen studies met our inclusion criteria. When botulinum injection was compared with a non-sham control, it was found to be effective at improving calf muscle tone (one month: -2.73 (confidence interval (CI) -3.42 to -2.04), three months: -1.72 (-2.68 to -0.76)), passive ankle range of motion (one month: 3.29 (CI 2.52 to 4.05), three months: 1.00 (CI 0.44 to 1.56)) and gait speed (one month: 0.91 (CI 0.29 to 1.53), three months: 0.61 (CI 0.01 to 1.21)) for four months, as well as Gross Motor Function Measure (2.02 (CI 1.30 to 2.75)) for two months. When compared with sham injection, botulinum injection was only effective on Gross Motor Function Measure (0.98 (CI 0.28 to 1.69)) after four months. CONCLUSIONS Although we found evidence supporting the efficacy of botulinum toxin A in studies comparing botulinum injection with non-sham controls, we did not find clear evidence of support in studies comparing botulinum injection with sham injection.
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Affiliation(s)
- Yun Hyung Koog
- Kyung Hee University, Department of East-West Medicine, Seoul, Republic of Korea
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Molenaers G, Van Campenhout A, Fagard K, De Cat J, Desloovere K. The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb. J Child Orthop 2010; 4:183-95. [PMID: 21629371 PMCID: PMC2866843 DOI: 10.1007/s11832-010-0246-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 02/12/2010] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb. BACKGROUND The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, "reflection is more important than injection" remains an actual statement.
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Affiliation(s)
- Guy Molenaers
- />Department of Paediatric Orthopaedics, University Hospital Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium
- />Musculoskeletal Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Anja Van Campenhout
- />Department of Paediatric Orthopaedics, University Hospital Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium
- />Musculoskeletal Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Katrien Fagard
- />Clinical Motion Analysis Laboratory, University Hospital Pellenberg, Pellenberg, Belgium
| | - Jos De Cat
- />Clinical Motion Analysis Laboratory, University Hospital Pellenberg, Pellenberg, Belgium
| | - Kaat Desloovere
- />Clinical Motion Analysis Laboratory, University Hospital Pellenberg, Pellenberg, Belgium
- />Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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[Botulinum toxin A in children with infantile cerebral palsy: indications and treatment concepts]. DER ORTHOPADE 2010; 39:23-30. [PMID: 20033394 DOI: 10.1007/s00132-009-1534-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Botulinum toxin A treatment in children with cerebral palsy is now well established as a safe and effective therapy option. However, a standardised injection strategy is still lacking. There is no doubt concerning the necessity for long-term therapy to cover the duration of motor development as well as for adequate prevention of fixed contractures. The appropriate dose and treatment concept to be used, however, is still controversial. The modern BoNT-A treatment concept must combine safety and efficacy with the availability of this treatment option throughout the duration of growth in these children. Consequently, in order to provide the best possible support for motor development at each individual motor milestone and using moderate dose recommendations, the "Key-Muscle Concept" has been developed.
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Compartment Syndrome After Serial Casting in Spastic Diplegic Cerebral Palsy: A Case Report. Arch Phys Med Rehabil 2010; 91:653-5. [DOI: 10.1016/j.apmr.2009.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 11/28/2009] [Accepted: 12/17/2009] [Indexed: 11/23/2022]
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The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol 2010; 14:45-66. [PMID: 19914110 DOI: 10.1016/j.ejpn.2009.09.005] [Citation(s) in RCA: 157] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/15/2009] [Accepted: 09/17/2009] [Indexed: 12/20/2022]
Abstract
An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.
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Botulinumtoxin als Teil einer integrierten Behandlung. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-2040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Papavasiliou AS. Management of motor problems in cerebral palsy: a critical update for the clinician. Eur J Paediatr Neurol 2009; 13:387-96. [PMID: 18778959 DOI: 10.1016/j.ejpn.2008.07.009] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 07/22/2008] [Indexed: 11/17/2022]
Abstract
Currently there is no specific treatment for the brain insults leading to motor dysfunction in cerebral palsy. The available symptomatic therapeutic options place cerebral palsy among the costliest chronic childhood conditions. Therefore, it is necessary to make well-informed decisions in an effort to match cost-effectiveness with patient and family needs. This presentation aims to analyze the efficacy of rehabilitation therapy, orthoses, oral medications, botulinum toxin, intrathecal baclofen, complementary or alternative treatments and discuss guidelines for a goal oriented approach. Despite insufficient reporting of trials, physiotherapy has shifted from traditional to goal oriented approaches, based on principles of motor learning, strength and fitness training. Correct choice and use of orthoses is stressed, yet evidence from primary studies is limited. Pharmacological treatments of spasticity (oral agents, botulinum toxin, intrathecal baclofen) may be alternatives or supplements to orthopaedic surgery. There is evidence that botulinum toxin combined with conservative treatments reduces the number of complex orthopaedic interventions. Intrathecal baclofen effectively reduces spasticity; criteria describing the ideal candidate are needed. Complementary or alternative treatment use is widespread; research needs to determine what factors make these modalities desirable and effective in cerebral palsy. It is concluded that the introduction of new therapies facilitates an individualized management plan. Multimodal treatment is optimized with a multidisciplinary team. Outcome measurement according to the World Health Organization's new International Classification of Functioning, Disability and Health is emphasized.
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Affiliation(s)
- Antigone S Papavasiliou
- Department of Neurology, Pendeli Children's Hospital, 8 Hippocrates street, Palia Pendeli, 15236, Athens, Greece.
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Grafikgestützter Konsensus für die Behandlung von Bewegungsstörungen bei Kindern mit bilateralen spastischen Zerebralparesen (BS-CP). Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-2001-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Cerebral palsy is the most prevalent cause of persisting motor function impairment with a frequency of about 1/500 births. In developed countries, the prevalence rose after introduction of neonatal intensive care, but in the past decade, this trend has reversed. A recent international workshop defined cerebral palsy as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain." In a majority of cases, the predominant motor abnormality is spasticity; other forms of cerebral palsy include dyskinetic (dystonia or choreo-athetosis) and ataxic cerebral palsy. In preterm infants, about one-half of the cases have neuroimaging abnormalities, such as echolucency in the periventricular white matter or ventricular enlargement on cranial ultrasound. Among children born at or near term, about two-thirds have neuroimaging abnormalities, including focal infarction, brain malformations, and periventricular leukomalacia. In addition to the motor impairment, individuals with cerebral palsy may have sensory impairments, cognitive impairment, and epilepsy. Ambulation status, intelligence quotient, quality of speech, and hand function together are predictive of employment status. Mortality risk increases incrementally with increasing number of impairments, including intellectual, limb function, hearing, and vision. The care of individuals with cerebral palsy should include the provision of a primary care medical home for care coordination and support; diagnostic evaluations to identify brain abnormalities, severity of neurologic and functional abnormalities, and associated impairments; management of spasticity; and care for associated problems such as nutritional deficiencies, pain, dental care, bowel and bladder continence, and orthopedic complications. Current strategies to decrease the risk of cerebral palsy include interventions to prolong pregnancy (eg, 17alpha-progesterone), limiting the number of multiple gestations related to assisted reproductive technology, antenatal steroids for mothers expected to deliver prematurely, caffeine for extremely low birth weight neonates, and induced hypothermia for a subgroup of neonates diagnosed with hypoxic-ischemic encephalopathy.
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