Injectable neuromuscular blockade in the treatment of spasticity and movement disorders

Safety and effectiveness of ethanol neurolysis with and without onabotulinumtoxinA in children with cerebral palsy

BACKGROUND

OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles but is less well studied, especially in pediatrics.

OBJECTIVE

To determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy.

DESIGN

Prospective cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021.

SETTING

Outpatient physiatry clinic.

PATIENTS

A total of 167 children with cerebral palsy not undergoing other treatments during injection period.

INTERVENTIONS

Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation.

MAIN OUTCOME MEASURES

A post-procedure evaluation at 2 weeks after injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1 to 5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System, gender, age, weight, ethnicity, race, and dosage.

RESULTS

Only weight was identified as a confounding factor. When controlled for weight, combined onabotulinumtoxinA and ethanol injections had a greater magnitude of improvement (3.78/5) compared with onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (95% confidence interval: 0.01-0.69; p = .045). However, the difference was not clinically significant. One patient in the onabotulinumtoxinA-only group and two patients in the combined onabotulinumtoxinA and ethanol group reported mild, self-limiting adverse effects.

CONCLUSION

Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.

Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study

BACKGROUND

Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait.

OBJECTIVE

The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients.

METHODS

In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018.

METHODS

Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent).

RESULTS

Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection.

CONCLUSION

Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.

Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status

Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.

Use of Shear Wave Elastography for Quantitative Assessment of Muscle Stiffness After Botulinum Toxin Injection in Children With Cerebral Palsy

OBJECTIVES

This study aimed to investigate the stiffness of the gastrocnemius (GC) muscle with acoustic radiation force impulse (ARFI) elastography after botulinum toxin-A (BTX-A) injection in children with spastic cerebral palsy (CP) and to examine the relationship between elastographic and clinical parameters.

METHODS

This prospective randomized single-blind controlled clinical study included 49 lower extremities of 33 children with spastic CP. They were randomized into 2 groups: group 1 (n = 25 extremities in 17 children) received BTX-A injection and a home-based exercise program; group 2 (n = 24 extremities in 16 children) received only a home-based exercise program. Patients were evaluated in pretreatment and posttreatment periods in the first and third months with ARFI elastography, the Modified Ashworth Scale, Modified Tardieu Scale, Pediatric Functional Independence Measure, Gross Motor Function Classification System, and goniometric range of motion measurement of the ankle.

RESULTS

A statistically significant difference was found in elastography of the GC muscle in group 1 only at the first month after treatment (P < .05). No statistical difference was found in elastography of the GC after treatment in group 2. According to the Modified Ashworth Scale, Modified Tardieu Scale, and ankle passive range of motion, group 1 showed significant improvements after treatment (P < .05). Also, there was a significant correlation between these clinical parameters and elastographic measurements (P < .05).

CONCLUSIONS

According to the results of this study, the measurements from ARFI elastography combined with clinical parameters might be useful for evaluation of spasticity after BTX-A treatment in children with CP. Also, they might be useful in distinguishing patients who will benefit clinically, especially in the early stages of treatment.

The Minimum Data Set: An Opportunity to Improve Spasticity Screening

Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.

Prevalence of Spasticity in Nursing Home Residents

OBJECTIVES

To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services.

METHODS

Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency.

RESULTS

Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ² = 51.72, P < .001), which was driven by lower limb spasticity (χ² = 14.56, P = .006).

CONCLUSIONS AND IMPLICATIONS

These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.

Effect of extracorporeal shockwave therapy on muscle spasticity in patients with cerebral palsy: meta-analysis and systematic review

INTRODUCTION

Recently, clinical trials have been performed to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) in patients with cerebral palsy (CP). However, various studies adopted different clinical scales, making it insufficient to draw a definite conclusion about the efficacy of ESWT in reducing spasticity after cerebral palsy. The purpose of this meta-analysis was to assess the effects of ESWT on reducing spasticity after applying ESWT in patients with CP.

EVIDENCE ACQUISITION

In accordance with the PRISMA statement, authors searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and Scopus from their inception dates through December 11th 2018. We included randomised controlled trials in any language that using ESWT for the purpose of ameliorating spasticity in patients with CP. We assessed spasticity measured by modified Ashworth Scale (MAS), range of motion (ROM) and baropodometric values as outcomes.

EVIDENCE SYNTHESIS

Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesised narratively. From a total of 206 articles, 16 manuscripts were selected and 5 of them were ultimately included in this meta-analysis. MAS grade as primary outcome was significantly improved after ESWT compared to that in the control group (mean difference [MD]: -0.62; 95% CI: -1.52 to -0.18). ROM after ESWT was also significantly improved compared to that in the control groups (MD: 18.01; 95% CI: 6.11 to 29.91). Baropodometric measures showed significantly increases in foot contact area during gait (SMD: 29.00; 95% CI: 11.08 to 46.92), but not significantly in peak pressure under the heel (MD: 15.12; 95% CI: -1.85 to 32.10) immediately after ESWT.

CONCLUSIONS

No serious side effects were observed in any patient after ESWT. ESWT may be a valid alternative to existing treatment options targeting spasticity diminishment and ROM improvement in CP patients to maintain healthy lifestyles and normalize spastic gait pattern. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow-up studies are needed to verify our results.

Quantifying Effect of Onabotulinum Toxin A on Passive Muscle Stiffness in Children with Cerebral Palsy Using Ultrasound Shear Wave Elastography

OBJECTIVE

A pilot study was conducted to longitudinally quantify effect of onabotulinum toxin A (BoNT-A) on passive muscle properties in children with cerebral palsy using ultrasound shear wave elastography.

DESIGN

This was a prospective longitudinal cohort study.

RESULTS

Between 1 and 3 mos post-BoNT-A, a significant improvement in the shear modulus of the lateral gastrocnemius was found at 10-degrees plantar flexion (PF) (-7.57 [-10.98, -5.07], P = 0.02) and 0-degrees PF (-14.74 [-18.21, -9.38], P = 0.03). There was a notable, but nonsignificant, difference in shear modulus at 20-degrees PF, 10-degrees PF, and 0-degrees PF between pre-BoNT-A and 1 mo post-BoNT-A. Pre-BoNT-A shear modulus was not significantly different from 3 mos post-BoNT-A at all foot positions. No significant differences in ankle passive range of motion or spasticity were found.

CONCLUSION

Despite no significant change in ankle range of motion or spasticity, shear wave elastography was able to detect a difference in lateral gastrocnemius passive muscle properties in children with cerebral palsy after BoNT-A injections. The difference in passive muscle properties resolved by 3 mos post-BoNT-A.

Safety of combined salivary gland and multilevel intramuscular onabotulinumtoxinA injections with and without ethanol in pediatric patients with cerebral palsy: A retrospective study

OBJECTIVE

To evaluate the safety of combining salivary gland onabotulinumtoxinA (BTX-A) injections for sialorrhea with intramuscular BTX-A injections for spasticity in the same procedure.

DESIGN

A retrospective cohort study in a tertiary hospital center. Patients selected were younger than 20 years, diagnosed with cerebral palsy, and received their first salivary gland BTX-A injection between March 2011 and July 2015. Chart review and telephone interviews were performed. The primary outcome measure was the rate of adverse events after combined BTX-A injections into salivary glands and muscles. The secondary outcome measure was the efficacy of injections, as reported by patients.

RESULTS

Twenty-five of the 52 selected patients received salivary gland BTX-A injections only, and 27 received concurrent salivary gland and multi-level intramuscular chemodenervation with BTX-A with or without alcohol. The rate of adverse events was < 10% in both groups; 4% in "Salivary Only Group" and 7% in the "Salivary + Multilevel Intramuscular Chemodenervation with BTX-A group (with or without alcohol)". Both approaches were equally effective in meeting their goals of salivary injections (> 50% improvement for at least two months). In the "salivary only" and in the "salivary + multi-level intramuscular" group, 76 and 85% of the patients reached their goals respectively.

CONCLUSIONS

Combining BTX-A injections for sialorrhea with multilevel intramuscular BTX-A injections (with or without alcohol) appears to be safe and effective and allows treatment of patients for both conditions simultaneously.

Early predictors of developing problematic spasticity following traumatic spinal cord injury: A prospective cohort study

Objective: To identify early predictors and develop reliable, validated prediction models for development of problematic spasticity after traumatic spinal cord injury (SCI).Design: Prospective cohort study of the Rick Hansen Spinal Cord Injury Registry (RHSCIR), retrospective review of inpatient medical charts.Setting: Quaternary trauma center, rehabilitation center, community settings.Participants: Individuals with traumatic SCI between March 1, 2005, and March 31, 2014, prospectively enrolled in the Vancouver site RHSCIR.Interventions: None.Main Outcome Measure: Spasticity limiting function or requiring treatment (problematic spasticity) on the Spinal Cord Injury Health Questionnaire.Results: In 350 patients, variables documented during hospitalization that predicted the development of problematic spasticity up to 5 years post-injury included: initial Glasgow Coma Scale; age at time of injury; admission to rehabilitation center; community discharge anti-spasticity medication prescription, neurological status, Penn Spasm Frequency Scale, and pain interference with quality of life, sleep, activities; greater change in AIS motor scores between admission and discharge. The predictive models had area under the receiver operating characteristic curve of 0.80 (95% CI 0.75, 0.85) in the development set (N = 244) and 0.84 (95% CI 0.74, 0.92) in the validation set (N = 106) for spasticity limiting function and 0.81 (95% CI 0.76, 0.85) in the development set and 0.85 (95% CI 0.77, 0.92) in the validation set for spasticity requiring treatment.Conclusions: Our prediction models provide an early prognosis of risk of developing problematic spasticity after traumatic SCI, which can be used to improve clinical spasticity management and assist research (e.g. risk stratification in interventional trials).

Treatment patterns of in-patient spasticity medication use after traumatic spinal cord injury: a prospective cohort study

STUDY DESIGN

Prospective cohort study using the Rick Hansen SCI Registry (RHSCIR) and retrospective medical chart review.

OBJECTIVE

To describe treatment patterns of in-patient anti-spasticity medication use following traumatic spinal cord injury (SCI) in acute and rehabilitation hospital settings in British Columbia, Canada.

SETTING

Quaternary trauma center, rehabilitation center.

METHODS

Individuals with traumatic SCI between 2005 and 2014 enrolled in the Vancouver RHSCIR site (N = 917) were eligible for inclusion. Oral and injectable anti-spasticity medication use were the main outcome measures.

RESULTS

In 769 participants, higher neurological level and injury severity were associated with in-patient anti-spasticity medication use (p < 0.001 for both). Of individuals with cervical and thoracic injuries (n = 589), 37% were prescribed anti-spasticity medication during hospital admission. Baclofen was the most commonly used first line oral therapy. Mean (SD) and median time from injury to Baclofen initiation was 70 (69) and 50 days, respectively. The probability of having initiated an in-patient anti-spasticity medication was 55% (95% CI (49, 60)) for individuals 6 months post-injury, and 71% (95% CI (62, 79)) for individuals 12 months post-injury. At community discharge, the prevalence of oral and injectable anti-spasticity medication use was 26 and 5%. Practice patterns of anti-spasticity medication use (2005-2009 vs. 2010-2014) have not changed significantly over time.

CONCLUSIONS

This is the first large prospective cohort study of in-patient anti-spasticity medication use following traumatic SCI. Results from our study inform clinicians and individuals of "real world" anti-spasticity medication use among individuals with traumatic SCI and may help guide care for this population in the community.

Special Considerations in Pediatric Assessment

Pediatric spasticity management requires special consideration because of continuous growth and underlying medical complications due to upper motor neuron disease. Early intervention, regular follow-up, and management of spasticity are critical to improve function and prevent musculoskeletal complications, functional deterioration, and the development of pain. Thorough history taking along with comprehensive medical evaluation and physical examination by practitioners with knowledge about spasticity are important clues for spasticity management in addition to thorough history taking and review of current medications. This article reviews the rationale of early intervention and continuum of care, basic physical examination, and therapeutic options for spasticity management and spasticity's aggravating factors.

The effect of dry needling on spasticity, gait and muscle architecture in patients with chronic stroke: A case series study

Objectives The objective of this study was to assess the short-term effects of dry needling on spasticity, gait, and muscle architecture of patients with chronic stroke. Methods A case series study was designed; and six chronic stroke patients with ankle spasticity and gait impairment received a single session of dry needling for gastrocnemius medialis, lateralis, and soleus muscles. The main outcome measures were the Modified Modified Ashworth Scale (MMAS), and Timed Up and Go test (TUG). In addition, ultrasonography measurements (e.g. thickness, pennation angle, and fascicle length) were performed for gastrocnemius medialis at baseline (T0), immediately after intervention (T1) and 30 min after intervention (T2), while the MMAS and TUG Test were only measured at T0 and T2. Results Based on the TUG test, there was a significant improvement in gait function (p = 0.023). Furthermore, the MMAS results (p = 0.014) showed a decrease in resistance to passive movements from plantar flexor muscles. Furthermore, a significant decrease in pennation angle (p = 0.014) and muscle thickness (p = 0.001), and also a significant increase in fascicle length of gastrocnemius medialis (p = 0.001) were observed after dry needling. Discussion & conclusions Based on the outcomes of this study, dry needling application seems to have short term effects in terms of reducing spasticity, improving gait, and muscle architecture of gastrocnemius medialis in patients with chronic stroke. The changes of muscle architecture may be interpreted as the positive effects of dry needling on the physical properties of hypertonic muscles.

A Prospective Case-Control Study of Radial Extracorporeal Shock Wave Therapy for Spastic Plantar Flexor Muscles in Very Young Children With Cerebral Palsy

To assess the effects of radial extracorporeal shock wave therapy (rESWT) on plantar flexor muscle spasticity and gross motor function in very young patients with cerebral palsy (CP).The design was case-control study (level of evidence 3).The setting was the Department of Pediatric Neurology and Neurorehabilitation, First Hospital of Jilin University, Changchun, China.Those with a diagnosis of CP and spastic plantar flexor muscles were recruited between April 2014 and April 2015.According to the parents' decision, patients received 1 ESWT session per week for 3 months, with 1500 radial shock waves per ESWT session and leg with positive energy flux density of 0.03 mJ/mm, combined with traditional conservative therapy (rESWT group) or traditional conservative therapy alone (control group).The Modified Ashworth Scale (MAS) (primary outcome measure) and passive range of motion (pROM) measurements were collected at baseline (BL), 1 month (M1), and 3 months (M3) after BL. The Gross Motor Function Measure (GMFM)-88 was collected at BL and M3.Sixty-six patients completed the final review at 3 months and were included in the study. Subjects ranged in age from 12 to 60 months (mean age 27.0 ± 13.6 months; median age 22.0 months; 33.3% female). For the rESWT group (n = 34), mean MAS grades at BL, M1, and M3 were 2.6, 1.9, and 1.5 on the left side and 1.9, 1.7, and 1.2 on the right side. For the control group (n = 32), mean MAS grades at BL, M1, and M3 were 2.5, 2.4, and 2.1 on the left side and 1.8, 1.8, and 1.5 on the right side. The within-subject effects time × side and time × treatment were statistically significant (P < 0.01). Similar results were found for the improvement of mean pROM. GMFM-88 improved from BL to M3, but showed no statistically significant difference between the groups. There were no significant complications.This study demonstrates that the combination of rESWT and traditional conservative therapy is more effective than traditional conservative therapy alone in the treatment of spasticity in very young patients with CP.

Ketamine-based procedural sedation and analgesia for botulinum toxin A injections in children with cerebral palsy

INTRODUCTION

Adequate procedural sedation and analgesia (PSA) is essential to reduce pain and distress for children undergoing intramuscular botulinum toxin (BoNT-A) injections. This study describes our institution's experience with ketamine-based PSA in terms of safety and efficacy in children with cerebral palsy receiving BoNT-A injections.

MATERIAL AND METHODS

This is an analysis of ketamine-based PSA for children undergoing BoNT-A injections between January 2000 and October 2014. All patients received PSA according to our institution's sedation protocol. From 2000 to 2012, intravenous ketamine and midazolam PSA was administered. From 2013 onwards, intravenous ketamine was used as a sole agent for PSA.

RESULTS

A total of 152 BoNT-A procedures were performed successfully on 87 children. The median age of the children was 5 years 5 months with 9 children younger than 36 months. Ten procedures (6.6%) were associated with acute transient self-limiting side effects: Four developed rashes, three had nausea and vomiting, one child had limb tremors and another child complained of mild headache. One child reported nightmares on the evening of the procedure during the two-week post-procedure review. No child experienced serious adverse events.

CONCLUSION

Administration of ketamine-based PSA for intramuscular BoNT-A procedures in children can be both safe and efficacious.

Effects of botulinum toxin A injection on healing and tensile strength of ruptured rabbit Achilles tendons

BACKGROUND

Tendon lacerations are most commonly managed with surgical repair. Postoperative complications such as adhesions and ruptures often occur with immobilization. Early postoperative mobilization is therefore advised to minimize complications and time required to return to daily life. The aim of this study was to evaluate whether botulinum neurotoxin type-A (BoNT-A) can be used to enhance healing and prevent rupture in mobilized animals with Achilles tenotomy.

METHODS

Twenty-seven rabbits were divided into 3 groups, namely, I, II, and III, after surgical 1-sided Achilles tenotomy and end-to-end repair. The control group for biomechanical comparisons consisted of randomly selected contralateral (unoperated) healthy Achilles tendons. Group I received BoNT-A (4 U/kg) injection into the calf muscles. One week later, electromyographical confirmation was performed to establish the effects of injection. Surgery was then performed. Animals in the second group (n = 9, group II) were immobilized with a cast postoperatively. The third group (n = 9, group III) was mobilized immediately with no cast or BoNT-A. Tendons were harvested and gap formation or ruptures as well as strength of the repaired tendon were assessed 6 weeks after surgery.

RESULTS

Achilles tendons healed in all animals injected with BoNT-A, whereas all were ruptured in group III. All Achilles tendons of animals in groups I and II healed. However, group I repaired tendons were biomechanically equivalent to healthy tendons, whereas group II repaired tendons demonstrated significantly decreased tensile strength (P = 0.009).

CONCLUSIONS

The present study suggests that local injection of BoNT-A can be used for treatment of tendon rupture and may replace the use of cast for immobilization. However, further studies are needed to determine whether BoNT-A injection can have a beneficial effect on the healing of tendon repairs in humans.

How to improve the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis in pain management in patients with pancreatic cancer: analysis in a single center

Visceral pain secondary to pancreatic cancer is often difficult to control and poses a challenge to the physician. We retrospectively analyzed the efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with unresectable pancreatic cancer. Forty-one patients with severe pain despite treatment with opioids underwent EUS-CPN with absolute alcohol. Patients scored their pain on a scale of 0 to 10 and were interviewed after the procedure. Of the 41 patients, 33, 37, and 25 patients reported improvement in their pain within 3 days, at 1 week, and at 3 months, respectively, following the procedure. Of all the patients, 19 patients reported substantial improvement and 4 patients showed complete disappearance of pain. Complication appeared in 2 patients with transient hypotension. In our study, EUS-CPN is a safe and effective form of treatment for intractable pain secondary to advanced pancreatic cancer.

The effect of obturator nerve block on hip lateralization in low functioning children with spastic cerebral palsy

PURPOSE

Hip adductor spasticity has a great impact on developing hip displacement in children with cerebral palsy (CP). Obturator nerve (ON) block is less invasive intervention rather than soft tissue surgery for reduction of hip adductor spasticity. The aim of this study is to investigate the effect of ON block on hip lateralization in low functioning children with spastic CP.

MATERIALS AND METHODS

The study was performed by retrospective investigation of the clinical and radiographic follow-up data of low functioning children [gross motor function classification system (GMFCS) level III to V] with spastic cerebral palsy whose hip was subluxated. Migration percentage (MP) was measured on hip radiographs and its annual change was calculated. In intervention group, ON block was done with 50% ethyl alcohol under the guidance of electrical stimulation.

RESULTS

The data of 49 legs of 25 children for intervention group and the data of 41 legs of 23 children for nonintervention group were collected. In intervention group, the MP were significantly reduced at 1st follow-up and the MPs at 2nd and last follow-up did not show significant differences from initial MP. Whereas in nonintervention group, the MPs at 1st, 2nd and last follow-up were all significantly increased compared to initial MPs.

CONCLUSION

ON block with ethyl alcohol is useful as an early effective procedure against progressive hip displacement in these children with spastic CP.

Evaluation of interadductor approach in neurolytic blockade of obturator nerve in spastic patients

BACKGROUND

Spasticity is a syndrome associated with a persistent increase in involuntary reflex activity of a muscle in response to stretch. Adductor muscle spasticity is a common complication of spinal cord and brain injury. It needs to be treated if it interferes with activities of daily living and self-care. Obturator neurolytic blockade is one of the cost-effective therapeutic possibilities to treat spasticity of adductor group of muscles. In this study, we assessed the efficacy of interadductor approach in alleviating the spasticity.

METHODS

Obturator neurolysis using 8-10 ml 6% phenol was given with the guidance of a peripheral nerve stimulator in 20 spastic patients. Technical evaluation included number of attempted needle insertions, time to accurate location of the nerve, depth of needle insertion, and success rate. Pain, spasticity, hip abduction range of motion (ROM), number of spasms, gait, and hygiene were evaluated at 1(st) hour, 24(th) hour, end of the 1(st) week, and in the 1(st), 2(nd), and 3(rd) months following the intervention.

RESULTS

The success rate was 100% with mean time to accurate nerve location 4.9±2.06 min. Average depth of needle insertion was 2.91±0.32 cm. Compared with the scores measured immediately before the block, all studied parameters improved significantly. An increase in the Modified Ashworth Scale values was observed in the 2(nd) and 3(rd) months, but they did not reach their initial values.

CONCLUSION

The interadductor approach proved to be accurate and fast, with a high success rate. Phenol blockade is an efficient and cost-effective technique in patients with adductor spasticity. It led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene, with an efficacy lasting for about 3 months.

Treatment of Morton neuroma with botulinum toxin A: a pilot study

BACKGROUND AND OBJECTIVE

Morton neuroma is a common cause of metatarsalgia of neuropathic origin. Systematic reviews suggest that insufficient studies have been performed on the efficacy of the different treatments available. OnabotulinumtoxinA has shown a degree of usefulness in other conditions associated with neuropathic pain. The aim of this study was to investigate the therapeutic potential of onabotulinumtoxinA in Morton neuroma.

PATIENTS AND METHODS

We present an open-label, pilot study with 17 consecutive patients with Morton neuroma and pain of more than 3 months' duration that had not responded to conservative treatment with physical measures or corticosteroid injection. Patients received one onabotulinumtoxinA injection in the area of the neuroma. The main outcome measure was the variation in the pain on walking evaluated using a visual analogue scale (VAS) before treatment and at 1 and 3 months after treatment. The secondary outcome was the change in foot function, which was assessed using the Foot Health Status Questionnaire.

RESULTS

In the overall group, the mean initial VAS score on walking was 7. This mean score had fallen to 4.8 at 1 month after treatment and to 3.7 at 3 months. Twelve patients (70.6 %) reported an improvement in their pain and five patients (29.4 %) reported no change; exacerbation of the pain did not occur in any patient. Improvements were also observed in two of the dimensions of the Foot Health Status Questionnaire: foot pain, which improved from a mean of 38.88 before treatment to 57 at 3 months, and foot function, which improved from a mean of 42.27 before treatment to 59.9 at 3 months. Clinical variables including age, sex, site and size of the lesion, standing activity, weekly duration of walking, footwear, foot type and footprint had no influence on the outcome. No adverse effects were reported.

CONCLUSIONS

In this pilot study, injection with onabotulinumtoxinA was shown to be of possible usefulness to relieve the pain and improve function in Morton neuroma. This finding opens the door to further clinical research.

Spread of botulinum neurotoxin type a at standard doses is inherent to the successful treatment of spastic equinus foot in cerebral palsy: short-term neurophysiological and clinical study

To evaluate whether botulinum toxin type A at standard doses spreads to antagonist leg muscles in dynamic equinus foot, we studied 18 ambulatory children with hemiplegic cerebral palsy. The gastrocnemius muscle on the affected side was injected with botulinum toxin type A (Dysport) (mean ± standard deviation, 14.3 ± 0.9 U/kg). Compound muscle action potential areas were assessed in the lateral gastrocnemius and tibialis anterior muscles on the treated and untreated sides before botulinum toxin type A injections and on days 10 and 30 after injections. In all patients, compound muscle action potential areas recorded from both the muscles on the treated side decreased from preinjection values at day 10 (P < .05) and 30 (P < .002). After injection, ankle spasticity had diminished (P < .05), equinus foot excursion increased (P < .05), and functional gait improved (P < .05). This study shows that botulinum toxin type A spreads from foot flexors to antagonist extensors and suggests that spread may be partly responsible for improving gait in children with cerebral palsy.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Selective percutaneous myofascial lengthening of the lower extremities in children with spastic cerebral palsy

Children with spastic cerebral palsy commonly acquire lower extremity musculoskeletal deformities that at some point may need surgical correction. The authors present 58 children with spastic cerebral palsy who underwent selective percutaneous myofascial lengthening of the hip adductor group and the medial or the lateral hamstrings. All the patients were spastic diplegic, hemiplegic, or quadriplegic. The indications for surgery were a primary contracture that interfered with the patients' walking or sitting ability or joint subluxation. Gross motor ability and gross motor function of the children were evaluated using the gross motor function classification system (GMFCS) and the gross motor function measure (GMFM), respectively. The mean time of the surgical procedure was 14 minutes (range, 1 to 27 minutes). All patients were discharged from the hospital setting the same day after the operation. There were no infections, overlengthening, nerve palsies, or vascular complications. Three patients required repeat procedures for relapsed hamstring and adductor contractures at 8, 14, and 16 months postoperatively. At 2 years after the initial operation, all the children improved on their previous functional level; 34 children improved by one GMFCS level, and 5 children improved by two GMFCS levels. The overall improvement in mean GMFM scores was from 71.19 to 83.19.

Neurolytic phenol blockade of the obturator nerve for severe adductor spasticity

BACKGROUND

In this study, we present the 3-month follow-up results of a retrospective analysis of obturator nerve (ON) phenol neurolysis performed between 2000 and 2007 in patients with adductor spasticity.

METHODS

The study was performed by retrospective investigation of the clinical follow-up results of 80 ON phenol treatments in 62 patients. Neurolysis using 5-10 ml 6% phenol was applied with the guidance of fluoroscopy and a peripheral nerve stimulator. Pain, spasticity and hygiene were evaluated and the hip abduction range of motion (ROM) was measured at the end of the first week and in the first, second and third months following the intervention.

RESULTS

The visual analogue scale scores decreased significantly in the first week, first month and the second month, but reached their initial values in the third month. A drastic increase in the ROM values was shown in hip abduction in the first week, first month and second month. An increase in the Ashworth Scale values was observed in the second and third months, but they did not reach their initial values. The hygiene score decreased drastically in the first week and the first and second months, but worsened in the third month. The success rate in nerve localization during ON neurolysis was 100%.

CONCLUSION

ON phenol blockade with fluoroscopy and peripheral nerve stimulator guidance in patients with adductor spasticity led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene with an efficacy lasting for about 3 months.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

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.

New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy

Cerebral palsy (CP) is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations. This article focuses on current and future intervention strategies for improving mobility and participation during the lifespan for ambulatory children with CP. The provision and integration of physical therapy and medical and orthopedic surgery management focused primarily on the lower extremities are discussed here. Some of the newer trends are more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who face a lifelong disability with unique challenges at each stage in life.

Management of spasticity in children with cerebral palsy

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.

Botulinum toxin: description of injection techniques and examination of controversies surrounding toxin diffusion

The benefits derived from botulinum toxin (BTX) injections may be negated by unintentional weakness of adjacent uninjected muscles. Such weakness may be the result of inaccurate targeting, or diffusion of BTX to surrounding muscles. Several techniques, using electromyographic, endoscopic or imaging guidance are purported to increase the accuracy of targeting. Diffusion of BTX is thought to be influenced by factors such as dose, concentration, injectate volume, number of injections, site and rate of injection, needle gauge, muscle size, muscular fascia, distance of needle tip from the neuromuscular junction, and protein content of the BTX formulation. This article describes techniques that aim to increase the accuracy of BTX injections and examines the controversies surrounding diffusion of BTX following injection.

Treatment of hypertension from renal artery entrapment by percutaneous CT-guided botulinum toxin injection into diaphragmatic crus as alternative to surgery and stenting

OBJECTIVE

Our objective was to describe the technique and outcome of CT-guided injection of botulinum toxin into the diaphragmatic crus in a patient with hypertension caused by left diaphragmatic crus compression of the left renal artery.

CONCLUSION

After the procedure, the patient's hypertension disappeared. We propose this technique, which directly targets inhibition of overactivity of the diaphragmatic crus, for treatment of hypertension caused by diaphragmatic compression of the renal artery as an alternative to surgery and renal artery stenting.

Evaluation of a multimodal management of prematurity-related spasticity

To examine the efficacy of a rehabilitation protocol, focusing on spasticity management through botulinum toxin A injections in the lower limbs, an etiologically homogeneous group of 57 prematurely born children with cerebral palsy was prospectively evaluated (minimum follow-up 18 months) under pragmatic conditions. Gross Motor Function Classification System categories were: I = 12, II = 9, III = 16, IV = 15, V = 4. Outcome was evaluated with goniometry, Gross Motor Function Measure, functional goal attainment at baseline and in subsequent months, the Gross Motor Function Classification System, functional mobility status, and parents' satisfaction at more than 18 months after first botulinum toxin. Goniometry demonstrated significantly improved range of movement in lower limbs at 10 days and 1 month after botulinum toxin. Differences persisted >18 months at the popliteal angles (P < 0.001). Gross Motor Function Measure changed significantly in 20 children (8 points in total score) at 3 months after first botulinum toxin (P < 0.0001) with less significant results thereafter. Predetermined functional goals were achieved in 61% at >18 months. Parents were satisfied in approximately 90% of the cases. Eighteen of 57 children (31.57%) changed Gross Motor Function Classification System status over a mean of 33.8 months (18-48) follow-up. Most significant gains were recorded in the severely involved group IV, where 10 of 15 (66.66%) improved. The high percentage of change in group IV implies the importance of gained sitting balance due to spasticity management.

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.

Management of spasticity in adults: practical application of botulinum toxin

Spasticity, characterized by increased muscle tone, exaggerated stretch reflexes, and abnormal limb posture, is a common sequel of central nervous system pathology. Historically, medicinal treatments have been of limited efficacy. This review discusses the clinical features of spasticity, the functional and pathological consequences, and treatment. It reviews the most common patterns of spasticity encountered in the upper and lower limbs and focuses on focal treatment of spastic muscles with the three commercially available botulinum toxins Botox, Dysport, and Myobloc/NeuroBloc. It addresses practical details such as muscle selection and identification, drug dilution, and doses.

How muscles recover from paresis and atrophy after intramuscular injection of botulinum toxin A: Study in juvenile rats

Botulinum toxin A (BoNT-A) is a potent biological toxin widely used for the management of skeletal muscle spasticity or dynamic joint contracture. Intramuscular injection of BoNT-A causes muscle denervation, paresis, and atrophy. This clinical effect of botulinum toxin A lasts 3 to 6 months, and injected muscle eventually regains muscle mass and recovers muscle function. The goal of the present study was to characterize the molecular and cellular mechanisms leading to neuromuscular junction (NMJ) regeneration and skeletal muscle functional recovery after BoNT-A injection. Fifty-six 1-month-old Sprague-Dawley rats were used. Botulinum toxin A was injected into the left gastrocnemius muscle at a dosage of 6 units/kg body weight. An equivalent volume of saline was injected into the right gastrocnemius muscle to serve as control. The gastrocnemius muscle samples were harvested from both hind limbs at 3 days, 7 days, 15 days, 30 days, 60 days, 90 days, 180 days, and 360 days after administration of toxin. In addition, the gastrocnemius muscles from 1-month-old rats with no injections were harvested to serve as uninjected control group. Muscle samples were processed and mRNA was extracted. Real-time polymerase chain reaction (PCR) and gene microarray technology were used to identify key molecules involved in NMJ stabilization and muscle functional recovery. More than 28,000 rat genes were analyzed and approximately 9000 genes are expressed in the rat gastrocnemius muscle. Seven days following BoNT-A injection, 105 genes were upregulated and 59 genes were downregulated. Key molecules involved in neuromuscular junction (NMJ) stabilization and muscle functional recovery were identified and their time course of gene expression following BoNT-A injection were characterized. This animal study demonstrates that following intramuscular injection of BoNT-A, there is a sequence of cellular events that eventually leads to NMJ stabilization, remodeling, and myogenesis and muscle functional recovery. This recovery process is divided into two stages (aneural and neural) and that the IGF-1 signaling pathway play a central role in the process.

Use of intra-articular administration of ethyl alcohol for arthrodesis of the tarsometatarsal joint in healthy horses

OBJECTIVE

To evaluate the efficacy and safety of intra-articular administration of ethyl alcohol for arthrodesis of tarsometatarsal joints in horses.

ANIMALS

8 healthy female horses without lameness or radiographic evidence of tarsal joint osteoarthritis.

PROCEDURE

In each horse, 1 tarsometatarsal joint was treated with 4 mL of 70% ethyl alcohol and the opposite joint was treated with 4 mL of 95% ethyl alcohol. Lameness examinations were performed daily for 2 weeks, followed by monthly evaluations for the duration of the 12-month study. Radiographic evaluations of both tarsi were performed 1 month after injection and every 3 months thereafter. Gross and histologic examinations of the tarsi were undertaken at completion of the study.

RESULTS

Horses had minimal to no lameness associated with the treatments. Radiography revealed that 8 of 16 joints were fused by 4 months after treatment, with significantly more joints fused in the 70% ethyl alcohol group. Fifteen of 16 joints were considered fused at postmortem examination at 12 months. Gross and histologic examinations revealed foci of dense mature osteonal bone spanning the joint spaces. Bony fusion appeared to be concentrated on the dorsolateral, centrolateral, and plantarolateral aspects of the joints. Significant differences were not detected between treatment groups for lameness or pathologic findings.

CONCLUSIONS AND CLINICAL RELEVANCE

Administration of ethyl alcohol into the tarsometatarsal joint of healthy horses appeared to facilitate arthrodesis of the joint in a pain-free manner. Results warrant further investigation into the potential use of ethyl alcohol in horses clinically affected with osteoarthritis of the tarsometatarsal and distal intertarsal joints.

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

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

Exploring strategies to prevent post-lobectomy space: transient diaphragmatic paralysis using Botulinum toxin type A (BTX-A)

Objective

Various techniques to reduce air space after pulmonary lobectomy especially for lung cancer have been an important concern in thoracic surgical practice. The aim of this study was to assess the effectiveness of Botulinum toxin A (BTX-A) injection into the diaphragm to reduce air space after right lower pulmonary lobectomy in an animal model.

Methods

Twelve male New Zealand rabbits were randomly allocated into two groups. All animals underwent right lower lobectomy. Then, normal saline of 0,1 ml and 10 units of 0,1 ml Botulinum toxin type A were injected into the muscular part of the right hemidiaphragm in control (n = 6) and BTX-A groups (n = 6) respectively. Residual air space and diaphragmatic elevation were evaluated with chest X-ray pre- and postoperatively. Diaphragmatic elevation was measured as a distance in millimetre from the line connecting the 10th ribs to the midpoint of the right hemidiaphragm.

Results

The mean diaphragmatic elevation in BTX-A and control groups were 7.0 ± 2.5 and 1.3 ± 1.2 millimetres respectively. Diaphragmatic elevations were significantly higher in BTX-A group (p = 0.0035).

Conclusion

Intraoperative Botulinum toxin type A injection may reduce postlobectomy spaces effectively via hemidiaphragmatic paralysis in rabbits. Further studies are needed to validate the safe use of Botulinum toxin type A in human beings.

Pharmacologic interventions for reducing spasticity in cerebral palsy

Motor function abnormalities are a key feature of cerebral palsy. Spasticity is one of the main motor abnormalities seen in children with cerebral palsy. Spasticity is a velocity dependent increased resistance to movement. While in some children, spasticity may adversely impact the motor abilities, in others, it may help maintain posture and ability to ambulate. Thus, treatment to reduce spasticity requires careful consideration of various factors. Non-pharmacologic interventions used to reduce spasticity include physiotherapy, occupational therapy, use of adaptive equipment, various orthopedic surgical procedures and neurosurgical procedures. Pharmacologic interventions used for reducing spasticity in children with cerebral palsy reviewed in this article include oral administration of baclofen, diazepam, dantrolene and tizanidine, intrathecal baclofen, and local injections of botulinum toxin, phenol, and alcohol.

Motor points for neuromuscular blockade of the adductor muscle group

We sought to identify the motor nerve points for the adductor muscle group, relate them to specific surface anatomy markings, and define the points in terms of percentage distances along an anatomic reference line. We dissected four muscles in each of 20 legs from 15 skeletally mature, formalin-preserved cadavers. Multiple motor branches occurred in 21 of the 80 muscles dissected, but in only four limbs were they observed for more than one muscle in the group. Motor points (defined as the entry point of the motor branch into the muscle) were identified for each muscle along a reference line from the symphysis pubis to the medial joint line at the distal extent of the medial femoral condyle. The mean motor points and 95% confidence limits were as follows: adductor longus, 31% +/- 1.1%; adductor brevis, 22% +/- 1.8%; adductor magnus, 38% +/- 2.5%; and gracilis, 44% +/- 3.1%. Identification of these motor points facilitates accurate placement of neuromuscular blocking agents, such as botulinum toxin, and may lead to increased clinical efficacy of the block with a reduction in local or systemic side effects.

Gene expression of nAChR, SNAP-25 and GAP-43 in skeletal muscles following botulinum toxin A injection: a study in rats

PURPOSE

Botulinum toxin A (BoNT-A) is used to manage spasticity in cerebral palsy. BoNT-A cleaves SNAP-25 protein, blocking acetylcholine release and weakening the muscle. Nicotinic acetylcholine receptors (nAChR) including alpha, beta, delta, gamma, and epsilon subunits, and GAP-43 protein are associated with functional recovery of neuromuscular junctions (NMJ) following BoNT-A. To better understand the mechanism behind this functional recovery, this study attempted to (1) document changes in NMJ morphometry following BoNT-A, and (2) determine the gene expression of nAChR subunits, SNAP-25, and GAP-43 protein.

METHODS

In this rat study (46 rats), 6 units/kg body weight of BoNT-A was injected into the gastrocnimus. NMJ morphometry and the time course of gene expression of nAChR subunits, SNAP-25, and GAP-43 were evaluated up to 1year post-injection.

RESULTS

NMJ morphometry: gutter depth was reduced vs. the control side at two months, and normalizing by 6 months following BoNT. nAChR alpha mRNA and gamma mRNA increased by 3 days, peaked at 7 days and returned to control levels; delta mRNA peaked at 3 days. Epsilon mRNA peaked by 7 days. SNAP-25 mRNA increased from 60 to 90 days, returning to control levels by 6 months. GAP-43 mRNA was unchanged.

CONCLUSIONS

Specific nAChR subunit mRNA expression up-regulates and then returns to normal within two weeks, preceding changes in NMJ morphometry. Although GAP-43 participates in nerve sprouting, no increase of GAP-43 mRNA occurred following BoNT-A. Delayed up-regulation of SNAP-25 mRNA might be associated with muscle functional recovery.

Management of spasticity in children with cerebral palsy

As one component of the upper motor neuron syndrome, spasticity can have a significant functional impact on the child with cerebral palsy. Treatment planning requires the determination that excess tone interferes with some aspect of function, comfort, or care, and takes into consideration carefully devised goals that meet the needs of the patient and the caregiver. Treatment options include physical therapy, oral medications, chemodenervation with botulinum toxin or phenol, rhizotomy, intrathecal baclofen, and orthopedic surgery. The uses and limitations of each is discussed, and evidence for efficacy in cerebral palsy is reviewed.