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Jardon M, Nguyen J, Casaletto E, Ko L, Wolff A, Daluiski A, Nwawka OK. Utilization of shear wave elastography to quantify and predict response to upper extremity botulinum toxin injections in patients with cerebral palsy: A pilot study. Clin Neurol Neurosurg 2023; 230:107798. [PMID: 37236005 DOI: 10.1016/j.clineuro.2023.107798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Shear wave elastography (SWE) was used to quantify change in upper extremity muscle stiffness in patients with unilateral spastic cerebral palsy (USCP) following botulinum toxin A (BTX-A) therapy. We hypothesized that SWE measures would decrease following ultrasound-guided BTX-A injection, and correlate with functional improvement. METHODS SWE measures of BTX-A treated muscles were recorded immediately pre-injection, and at 1-, 3- and 6-months post-injection. At the same timepoints, functional assessment was performed using the Modified Ashworth Scale (MAS), and passive and active range of motion (PROM and AROM) measures. Correlation of SWE with MAS, PROM and AROM, as well as the relationship between change in SWE and change in MAS, PROM and AROM was determined using Spearman's rank correlation coefficient and generalized estimating equation modeling. RESULTS 16 muscles were injected and longitudinally assessed. SWE and MAS scores decreased following BTX-A injection (p = 0.030 and 0.004, respectively), reflecting decreased quantitative and qualitative muscle stiffness. Decreased SWE reached statistical significance at 1- and 3-months, and 1-, 3- and 6-months for MAS. When comparing relative change in SWE to relative change in AROM, larger change in SWE strongly correlated with positive change in AROM (p-value range:<0.001-0.057). BTX-A responders also demonstrated lower baseline SWE (1.4 m/s) vs. non-responders (1.9 m/s), p = 0.035. CONCLUSION Ultrasound-guided BTX-A injections in patients with USCP resulted in decreased quantitative and qualitative muscle stiffness. Strong correlation between change in SWE and AROM, as well as the significant difference in baseline SWE for BTX-A responders and non-responders, suggests SWE may provide a useful tool to predict and monitor BTX-A response.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Nguyen
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY, USA
| | - Emily Casaletto
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Lydia Ko
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Aviva Wolff
- Leon Root, MD Motion Analysis Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Aaron Daluiski
- Division of Hand and Upper Extremity Surgery, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - O Kenechi Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA.
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Hedberg-Graff J, Granström F, Krumlinde-Sundholm L. Physical characteristics and upper-limb treatment with botulinum neurotoxin A in children with cerebral palsy: A population-based study. Dev Med Child Neurol 2023; 65:571-579. [PMID: 36177964 DOI: 10.1111/dmcn.15426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/03/2022]
Abstract
AIM To describe the use of upper-limb botulinum neurotoxin A (BoNT-A) treatment in a population-based sample of children with cerebral palsy (CP), by investigating whether factors may be related to a first upper-limb BoNT-A treatment and whether passive range of motion (ROM) is related to a first BoNT-A treatment after adjustment for confounders. METHOD Data from five regions in Sweden, in the national registry and follow-up programme for CP (CPUP), were collected for children with spastic or dyskinetic CP assessed between 2000 and 2017. CP subtypes, functional classification levels, and traffic-light-based passive ROM categories were investigated. Data were analysed with logistic regression (odds ratios). RESULTS Of a total of 496 children (317 males, 179 females; median 2 years, interquartile range 1-5 years, range 1-15 years at first measurement occasion), 22% (n = 108) had received upper-limb BoNT-A treatment, 45% of whom by 1 to 3 years of age. Those classified in Manual Ability Classification System levels IV and V showed the highest crude odds ratio for a first upper-limb BoNT-A treatment. Children with full passive ROM with tightness at the end of the movement range were most likely to receive an upper-limb BoNT-A treatment, also after adjustment for confounders. Thumb and forearm muscles were the most targeted at the first upper-limb BoNT-A treatment. INTERPRETATION Full passive ROM with tightness at the end of the movement range increases the likelihood of a first upper-limb BoNT-A treatment. This new traffic-light category is an aspect to consider in the dialogue about upper-limb BoNT-A. WHAT THIS PAPER ADDS Among children receiving upper-limb botulinum neurotoxin A (BoNT-A), 45% had their first treatment before the age of 4 years. Thumb and forearm muscles were the most treated with BoNT-A, finger flexor muscles the least. Full passive range of motion with tightness was related to first upper-limb BoNT-A treatment.
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Affiliation(s)
- Jenny Hedberg-Graff
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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3
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Centorame D, Rawicki B, Hennel S, Hoare B. Upper Limb Onabotulinumtoxin A Injections in Children Under 2 Years with Cerebral Palsy: A Retrospective Chart Review. J Child Neurol 2022; 37:949-955. [PMID: 36113444 DOI: 10.1177/08830738221124365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim: To report on the safety of using Onabotulinumtoxin A (OnaA) in the upper limb(s) of children <2 years of age with cerebral palsy and to describe a proactive clinical model of care in the management of upper limb impairment in children with cerebral palsy. Methods and procedures: Retrospective chart audit of 65 infants aged 13-23 months (mean 18.69) who received upper limb OnaA injections. Administration procedures, trends in muscle selection, and adverse events were examined. Results: Adverse events were reported in 6 (4%) of the 65 children. Across the study period, muscles that control thumb and forearm movements were most commonly injected. The number of OnaA injections to subscapularis and flexor digitorum profundus increased over this period. Conclusions and implications: OnaA is a safe treatment option for the short-term management of focal upper limb muscle overactivity in children under 2 years of age with cerebral palsy. In line with existing evidence, OnaA should always be considered as an adjunct to evidence-based therapy.
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Affiliation(s)
- Danni Centorame
- Department of Paediatrics, 2541Monash University, Clayton, Australia
| | - Barry Rawicki
- Department of Paediatrics, 2541Monash University, Clayton, Australia.,Victorian Paediatric Rehabilitation Service, 557360Monash Children's Hospital, Clayton, Australia
| | - Sabine Hennel
- Department of Paediatrics, 2541Monash University, Clayton, Australia.,Victorian Paediatric Rehabilitation Service, 557360Monash Children's Hospital, Clayton, Australia
| | - Brian Hoare
- Department of Paediatrics, 2541Monash University, Clayton, Australia.,School of Occupational Therapy, 2080La Trobe University, School of Occupational Therapy, Bundoora, Australia.,Department of Occupational Therapy, Cerebral Palsy Group, Carlton, Australia
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4
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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5
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Almina S, Karile Y, Audrone P, Indre B. Analgesic effect of botulinum toxin in children with cerebral palsy: A systematic review. Toxicon 2021; 199:60-67. [PMID: 34081932 DOI: 10.1016/j.toxicon.2021.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
Abstract
This review aims to determine the analgesic efficacy of botulinum toxin (BTX) for the management of pain in children with cerebral palsy (CP). During July and August 2020, a systematic literature search was performed using a mixture of subject headings and free text. The eligibility criteria for inclusion in the review were: (1) interventional studies, (2) participants: children aged 0-18 with CP, (3) participants were treated with BTX, (4) an outcome measure of pain or satisfaction with pain management, and (5) published in an English-language peer-reviewed journal. Eleven studies met the eligibility criteria; nine studies explored analgesic effects of BTX for hypertonia related pain and two for postoperative pain. The studies were of level II to level IV evidence. We identified one high-quality study, which provides level II evidence, and two observational studies that supported BTX therapy for muscle hypertonia related pain in non-ambulant children with CP (GMFCS levels IV and V). For children in GMFCS levels I to III, the evidence for the analgesic effects of BTX was contradictory possibly due to the heterogeneity of the studies and/or weak study design. Mixed evidence for the use of BTX to reduce pain after hip surgery was found likely due to differences in the surgical method, injection protocols, and outcome measures.
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Affiliation(s)
- Stramkauskaite Almina
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Ylaite Karile
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Prasauskiene Audrone
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Bakaniene Indre
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
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Andersson G, Renström B, Blaszczyk I, Domellöf E. Upper-extremity Spasticity-reducing Treatment in Adjunct to Movement Training and Orthoses in Children with Cerebral Palsy at Gross Motor Function- and Manual Ability Classification System Levels IV-V: A Descriptive Study. Dev Neurorehabil 2020; 23:349-358. [PMID: 31437072 DOI: 10.1080/17518423.2019.1655677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Covering a 20-year period of work with children with severe cerebral palsy (CP) within a Swedish habilitation service, changes in passive wrist extension with fingers extended (PWE-FE) and current hand function are described and compared between children receiving systematic upper-extremity treatment with botulinum neurotoxin type A and intervention programs from before 7 years of age (Group 1, n = 7), those whom for various reasons did not undergo this treatment (Group 2, n = 10), and those not having the option to receive treatment until later during childhood/adolescence (Group 3, n = 8). Group 3 showed more critical and less normal PWE-FE values for both wrists, and poorer hand function scores, particularly compared with Group 1. Findings cautiously suggest that repeated upper-extremity spasticity-reducing treatment and movement training/orthoses from an early age may help prevent critical loss of passive range of motion of the wrist joint flexion/extension and promote hand function development in children with severe CP.
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Affiliation(s)
- Gerd Andersson
- Habilitation Centre, Västerbotten County Council , Umeå, Sweden
| | - Barbro Renström
- Habilitation Centre, Västerbotten County Council , Umeå, Sweden
| | - Izabela Blaszczyk
- Department of Surgical and Perioperative Sciences, Hand and Plastic Surgery, Umeå University , Umeå, Sweden
| | - Erik Domellöf
- Habilitation Centre, Västerbotten County Council , Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Hand and Plastic Surgery, Umeå University , Umeå, Sweden.,Department of Psychology, Umeå University, Umeå, Sweden
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Afsharipour B, Chandra S, Li G, Rymer WZ, Suresh NL. Characterization of Differences in the Time Course of Reflex and Voluntary Responses Following Botulinum Toxin Injections in Chronic Stroke Survivors. IEEE Trans Neural Syst Rehabil Eng 2020; 28:1642-1650. [PMID: 32634101 DOI: 10.1109/tnsre.2020.2997213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Spasticity is a major impairment that can occur following a hemispheric stroke and is often treated with injections of botulinum toxin, a neurotoxin that impairs transmission at the neuromuscular junction. Hyperreflexia is a defining feature of spasticity. Our main objective here was to quantify the time course of changes in the deep tendon reflex (DTR) responses and voluntary activation capacity following BT injection as well as to track changes in a clinical assessment of spasticity. Four chronic stroke survivors, scheduled to receive BT in their Biceps Brachii(BB) as part of their clinical care plan, were recruited for repeated testing sessions over the course of 4 months post injection. Both surface BB EMG reflex response to bicipital tendon taps as well as signals of applied tendon tap forces were recorded before and up to 18 weeks post-BT. Voluntary force and biceps EMG signals were also recorded during maximum voluntary (isometric) contractions (MVC) at each testing session. Our results show major reductions (up to 75%) in voluntary sEMG and force arising between 11 to 35 days post-BT-injection. The stretch reflex gain declined two weeks after the maximal reductions in voluntary EMG and force. Paradoxically, there was a short-term increase in stretch reflex gain, in three out of four participants, approximately 11-35 days post BT. The time course of recovery of voluntary MVC and reflex responses varied considerably with a longer recovery time for the reflex responses.
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Yadav S, Chand S, Majumdar R, Sud A. Effect of botulinum toxin type-A in spasticity and functional outcome of upper limbs in cerebral palsy. J Clin Orthop Trauma 2020; 11:208-212. [PMID: 32099281 PMCID: PMC7026568 DOI: 10.1016/j.jcot.2020.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/05/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Spasticity has been considered to be a main contributor to both the impairment of function as well as posture in children with cerebral palsy (CP). Patterns of upper limb motor involvement in CP vary with resultant limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is a potent neurotoxin which acts by preventing the release of acetylcholine (Ach) from presynaptic axon at motor end plate reducing focal spasticity. With literature established role of BTX-A available for lower limb spasticity in CP, the purpose of this study was to present an objective analysis of the effect of a single i.m. injection of BTX-A in reduction of spasticity in the upper limb as well as functional outcome in children (4-12yrs) with spastic CP. METHODS A total of 28 patients (30 upper limbs) of spastic CP with minimum follow up of 6months were included in the study. Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were used to measure the spasticity. Surface landmarks were used to give I.m. Botox in selected spastic muscles followed by targeted rehabilitation. Functional outcomes were measured by MACS (Manual Ability Classification System) and Canadian Occupational Performance Measure (COPM) before treatment, at 3 and 6 months follow up. RESULTS Pronator teres was the most frequently injected muscle followed by FCU and Adductor pollicis. MAS scores at all joints and MTS scores at forearm deteriorated between 3 and 6 months. However, MACS and COPM showed sustained improvement at 3months and 6months with statistically significant change. CONCLUSION I.m. BTX-A injected using anatomical landmarks had significant improvement in both clinical and functional outcome measures. We noticed significant improvement in MACS and COPM at 6 months despite return of local spasticity. It is safe and effective for spasticity of upper limbs in cerebral palsy and capable of improving function without major side effects. MACS & COPM are easy to use, less time consuming & easily adjusted to local needs. Randomized control trials with long follow up are required in future with special focus on dosing and timing, scoring system for functional outcome as per regional needs and issue for antibody formation for repeat injections of BTX-A.
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Affiliation(s)
- Satender Yadav
- Department of Orthopedics, Lady Hardinge Medical College, 110001, New Delhi, India
| | - Suresh Chand
- Department of Orthopedics, Lady Hardinge Medical College, 110001, New Delhi, India,Corresponding author.
| | - Ritu Majumdar
- Department of Physical Medicine & Rehabilitation, Lady Hardinge Medical College, 110001, New Delhi, India
| | - Alok Sud
- Department of Orthopedics, Lady Hardinge Medical College, 110001, New Delhi, India
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Shierk A, Jiménez-Moreno AC, Roberts H, Ackerman-Laufer S, Backer G, Bard-Pondarre R, Cekmece C, Pyrzanowska W, Vilain C, Delgado MR. Development of a Pediatric Goal-Centered Upper Limb Spasticity Home Exercise Therapy Program for Use in a Phase-III Trial of Abobotulinumtoxina (Dysport ®). Phys Occup Ther Pediatr 2019; 39:124-135. [PMID: 30204515 DOI: 10.1080/01942638.2018.1486346] [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: 10/28/2022]
Abstract
AIMS To create a standardized home exercise therapy program that could be implemented by international sites to provide a consistent level of therapeutic intervention for pediatric patients participating in an ongoing Phase-III, randomized, controlled trial of repeat abobotulinumtoxinA injections for pediatric upper limb spasticity (NCT02106351). METHODS Physical therapists, occupational therapists, and medical doctors worked collaboratively to design an exercise therapy program to be implemented in the home setting. In this article, we describe the development process and the finalized program that is currently being used in the Phase-III trial. RESULTS The final program is presented as a "toolbox" for therapists, and includes a standardized step-wise process for choosing the most appropriate exercises and functional activities to achieve the agreed treatment goals of each abobotulinumtoxinA injection. The core toolbox includes: a clear protocol for clinicians, information sheets, signature of commitment forms, exercise score charts, and the library of exercises and functional activities that therapists choose from to aid the patient in achieving their treatment goals. CONCLUSIONS Implementation of this home therapy program provides a standardized background of good practice against which to test the efficacy of abobotulinumtoxinA. Preliminary data show that the program is readily accepted by patients and their families.
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Affiliation(s)
- Angela Shierk
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA
| | | | - Heather Roberts
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA
| | | | | | - Rachel Bard-Pondarre
- f Centre Médico-Chirurgical de Réadaptation des Massues - Croix-Rouge Française , Lyon , France
| | - Cigdem Cekmece
- g Department of Rehabilitation , Kocaeli University , Izmit , Turkey
| | - Weronika Pyrzanowska
- h Non-public Healthcare Unit Mazovian Neurorehabilitation and Psychiatry Center in Zagorze , Wiazowna , Poland
| | | | - Mauricio R Delgado
- a Texas Scottish Rite Hospital for Children , Dallas , TX , USA.,i Department of Neurology, University of Texas Southwestern Medical Center , Dallas , TX , USA
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10
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Abstract
Surgical management of upper limb spasticity has traditionally tackled the downstream effects at the muscle, tendon, and joint levels. Because this approach does not address the underlying pathologic condition within the nerve, surgical outcomes have been marked by unsatisfactory relapse over time. Future management may focus on reestablishing a normal neuronal impulse pathway to the dysfunctional musculotendinous unit. By severing the faulty γ-neuronal circuit at the C7 level, spasticity may be reduced. Transfer of the contralateral C7 nerve root to the injured C7 nerve root may open the potential for simultaneously restoring extension and improving reach and grasp functions.
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Affiliation(s)
- Mitchel Seruya
- Division of Plastic and Maxillofacial Surgery, USC Keck School of Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS#96, Los Angeles, CA 90027, USA.
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Xu J, Xia L, Shang Q, Du J, Zhu D, Wang Y, Bi D, Song J, Ma C, Gao C, Zhang X, Sun Y, Zhu L, Wang X, Zhu C, Xing Q. A Variant of the Autophagy-Related 5 Gene Is Associated with Child Cerebral Palsy. Front Cell Neurosci 2017; 11:407. [PMID: 29326554 PMCID: PMC5741640 DOI: 10.3389/fncel.2017.00407] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/04/2017] [Indexed: 12/19/2022] Open
Abstract
Cerebral palsy (CP) is a major cause of childhood disability in developed and developing countries, but the pathogenic mechanisms of CP development remain largely unknown. Autophagy is a highly conserved cellular self-digestion of damaged organelles and dysfunctional macromolecules. Growing evidence suggests that autophagy-related gene 5 (ATG5)-dependent autophagy is involved in neural development, neuronal differentiation, and neurological degenerative diseases. The aim of this study was to analyze ATG5 protein expression and gene polymorphisms in Chinese patients with CP and to evaluate the importance of ATG5 in the development of CP. Five polymorphisms from different regions of the ATG5 gene (rs510432, rs3804338, rs573775, rs2299863, and rs6568431) were analyzed in 715 CP patients and 658 controls using MassARRAY. Of these, 58 patients and 56 controls were selected for measurement of plasma ATG5 level using ELISA. The relevance of disease-associated SNPs was evaluated using the SHEsis program. We identified a significant association between rs6568431 and CP (OR = 1.388, 95% CI = 1.173~1.643, Pallele = 0.0005, Pgenotype = 0.0015). Subgroup analysis showed a highly significant association of rs6568431 with spastic CP (n = 468, OR = 1.511, 95% CI = 1.251~1.824, Pallele = 8.50e-005, Pgenotype = 1.57e-004) and spastic quadriplegia (OR = 1.927, 95% CI = 1.533~2.421, Pallele = 7.35e-008, Pgenotype = 3.24e-009). Furthermore, mean plasma ATG5 levels were lower in CP patients than in controls, and individuals carrying the AA genotype of rs6568431 that was positively associated with CP had lower plasma ATG5 levels (P < 0.05). This study demonstrated an association of an ATG5 gene variant and low level of ATG5 protein with CP, and stronger associations with severe clinical manifestations were identified. Our results provide novel evidence for a role of ATG5 in CP and shed light on the molecular mechanisms underlying this neurodevelopmental disorder.
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Affiliation(s)
- Jianhua Xu
- Institute of Biomedical Science and Children's Hospital, and Key Laboratory of Reproduction Regulation of the National Population and Family Planning Commission (NPFPC), Shanghai Institute of Planned Parenthood Research (SIPPR), IRD, Fudan University, Shanghai, China
| | - Lei Xia
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qing Shang
- Department of Pediatrics, Henan Children's Hospital, Zhengzhou, China
| | - Jing Du
- Institute of Biomedical Science and Children's Hospital, and Key Laboratory of Reproduction Regulation of the National Population and Family Planning Commission (NPFPC), Shanghai Institute of Planned Parenthood Research (SIPPR), IRD, Fudan University, Shanghai, China
| | - Dengna Zhu
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Child Rehabilitation Center, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yangong Wang
- Institute of Biomedical Science and Children's Hospital, and Key Laboratory of Reproduction Regulation of the National Population and Family Planning Commission (NPFPC), Shanghai Institute of Planned Parenthood Research (SIPPR), IRD, Fudan University, Shanghai, China
| | - Dan Bi
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Caiyun Ma
- Department of Pediatrics, Henan Children's Hospital, Zhengzhou, China
| | - Chao Gao
- Department of Pediatrics, Henan Children's Hospital, Zhengzhou, China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanyan Sun
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liping Zhu
- Shanghai Center for Women and Children's Health, Shanghai, China
| | - Xiaoyang Wang
- Perinatal Center, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The 3rd Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Qinghe Xing
- Institute of Biomedical Science and Children's Hospital, and Key Laboratory of Reproduction Regulation of the National Population and Family Planning Commission (NPFPC), Shanghai Institute of Planned Parenthood Research (SIPPR), IRD, Fudan University, Shanghai, China.,Shanghai Center for Women and Children's Health, Shanghai, China
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12
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Park H, Shin S, Shin HS, Kim HW, Kim DW, Lee DH. Is Botulinum Toxin Type A a Valuable Adjunct During Femoral Lengthening? A Randomized Trial. Clin Orthop Relat Res 2016; 474:2705-2711. [PMID: 27506971 PMCID: PMC5085937 DOI: 10.1007/s11999-016-5018-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/02/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reduced joint ROM and distraction-induced pain are common complaints of patients who have undergone gradual femoral lengthening. Attempts to reduce the effects of lengthening on joint motion have included the use of botulinum toxin to reduce the muscle forces that restrict motion. The benefits of this approach during femoral lengthening, however, have not been conclusively established. QUESTIONS/PURPOSES We wished to evaluate the effects of botulinum toxin type A (BtX-A) injection in the anterior thigh muscles during femoral distraction osteogenesis on adjacent joint ROM and distraction-induced pain. We asked: (1) Does injection of BtX-A in the quadriceps muscles lead to improved knee and hip motion during femoral lengthening? (2) Does injection of BtX-A reduce pain during femoral lengthening? METHODS A single-center, double-blind, randomized placebo-controlled trial was conducted. Forty-four patients (88 femurs) undergoing bilateral femoral lengthening for familial short stature were included in the study. BtX-A (200 IU) was injected intraoperatively in the quadriceps muscles of one thigh. An equal volume of sterile normal saline was injected in the other thigh as a control. Selection of the limb receiving the toxin was randomized. Clinical evaluation included a VAS score for pain measurement, ROM evaluation of the hips and knees, and measurement of thigh circumference. Side-to-side differences were analyzed throughout the entire consolidation phase. No patients were lost to followup, leaving 44 patients (88 femurs). The mean followup was 26 months (range, 14-40 months). The distraction rate and final length of gain were similar between treated and control limbs. A priori power analysis suggested that 44 legs were required in each group to achieve statistical significance of 0.05 with 90% power to detect a 50% difference in treatment effect between treatment and control groups. RESULTS There were no differences in hip ROM, knee ROM, or maximal thigh circumference between the two lower extremities at any time during the study period. VAS scores were no different between the patients who received BtX-A and those who received saline. CONCLUSIONS Local injection of 200 IU BtX-A in the quadriceps muscles does not appear to reduce distraction-induced pain nor enhance ROM in the hip or knee during femoral lengthening. Additional studies are needed to evaluate the effect of larger doses or different injection methods. Based on our findings, we do not recommend routine use of botulinum injections during limb lengthening and believe any further use of this drug should only be in the context of a controlled trial. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Hoon Park
- grid.15444.300000000404705454Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soowan Shin
- grid.42505.360000000121566853Department of Biological Sciences, University of Southern California, Los Angeles, CA USA
| | - Han Sol Shin
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Wook Kim
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Lee
- grid.15444.300000000404705454Division of Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
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13
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Lin YC, Lin IL, Chou TFA, Lee HM. Quantitative evaluation for spasticity of calf muscle after botulinum toxin injection in patients with cerebral palsy: a pilot study. J Neuroeng Rehabil 2016; 13:25. [PMID: 26969526 PMCID: PMC4788868 DOI: 10.1186/s12984-016-0135-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 03/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background Cerebral palsy (CP) is the most common pediatric disease to cause motor disability. Two common symptoms in CP are spasticity and contracture. If this occurred in the ankle plantar flexors of children with CP, it will impair their gait and active daily living profoundly. Most children with CP receive botulinum toxin type A (BoNT-A) injection to reduce muscle tone, but a knowledge gap exists in the understanding of changes of neural and non-neural components of spasticity after injection. The purpose of this study was to determine if our device for quantitative modified Tardieu approach (QMTA) is a valid method to assess spasticity of calf muscles after botulinum toxin injection. Methods In this study, we intended to develop a device for quantitative measurement of spasticity in calf muscles based on the modified Tardieu scale (MTS) and techniques of biomedical engineering. Our QMTA measures the angular displacement and resistance of stretched joint with a device that is light, portable and can be operated similar to conventional approaches for MTS. The static (R2), dynamic (R1) and R2-R1 angles derived from the reactive signals collected by the miniature sensors are used to represent the non-neural and neural components of stretched spastic muscles. Four children with CP were recruited to assess the change in spasticity in their gastrocnemius muscles before and 4 weeks after BoNT-A injection. Results A simulated ankle model validated the performance of our device in measuring joint displacement and estimating the angle of catch. Data from our participants with CP showed that R2 and R2-R1 improved significantly after BoNT-A administration. It indicates both neural and non-neural components of the spastic gastrocnemius muscles improved at four weeks after BoNT-A injection in children with CP. Conclusion Our device for QMTA can objectively measure the changes in spasticity of the gastrocnemius muscle in children with cerebral palsy after BoNT-A injection.
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Affiliation(s)
- Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.,Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.,Medical Device Innovation Center, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan
| | - I-Ling Lin
- Department of Medical Laboratory Sciences and Biotechnology, Kaohsiung Medical University, No 100, Shih-Chuan 1st Road, Kaohsiung City, 80708, Taiwan
| | - Te-Feng Arthur Chou
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.,School of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan
| | - Hsin-Min Lee
- Department of Physical Therapy, I-Shou University, No.8, Yida Rd., Jiaosu Village, Yanchao District, Kaohsiung City, 82445, Taiwan, ROC.
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14
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Lin YC, Huang CY, Lin IL, Shieh JY, Chung YT, Chen KL. Evaluating Functional Outcomes of Botulinum Toxin Type A Injection Combined with Occupational Therapy in the Upper Limbs of Children with Cerebral Palsy: A 9-Month Follow-Up from the Perspectives of Both Child and Caregiver. PLoS One 2015; 10:e0142769. [PMID: 26599003 PMCID: PMC4657995 DOI: 10.1371/journal.pone.0142769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To assess the effectiveness of combining botulinum toxin type A (BoNT-A) with functional occupational therapy (OT) at 9-month follow-up in children with cerebral palsy (CP) with bilateral upper limb impairments from the perspectives of both child and caregiver. Methods Twelve children with CP and their caregivers were assessed across 5 time points over 9 months based on the ICF after BoNT-A injection and functional OT in this open-label study. Results Significant differences were found across the 5 time points (p < .05) for both grasp and visual-motor integration with small effects (effect sizes = 0.12–0.24) and the self-care capability and performance of social function (p < .05). However, based on the effect sizes (0.02–0.14), no significant effects were found at the 4 post-test time points. Small effects were found on the psychological domain (effect sizes = 0.25–0.37) and environmental domains (effect size = 0.27) at follow-ups. Conclusion Combining a BoNT-A injection with OT not only reduced the muscle tone and increased ROM but also improved the upper limb function and self-care capability in children with CP. More importantly, these effects persisted for up to 9 months. Functional OT extends the effectiveness of a BoNT-A injection.
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Affiliation(s)
- Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Yu Huang
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - I-Ling Lin
- Department of Medical Laboratory Sciences and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jeng-Yi Shieh
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Yu-Ting Chung
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Lin Chen
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- School of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail:
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15
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Lin YC. Predicting the response to botulinum toxin treatment in children with cerebral palsy. Arch Phys Med Rehabil 2015; 96:760. [PMID: 25616395 DOI: 10.1016/j.apmr.2014.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/07/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, Tainan, Taiwan
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