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Facciorusso S, Spina S, Picelli A, Baricich A, Francisco GE, Molteni F, Wissel J, Santamato A. The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis. Toxins (Basel) 2024; 16:184. [PMID: 38668609 PMCID: PMC11053519 DOI: 10.3390/toxins16040184] [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: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024] Open
Abstract
Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.
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Affiliation(s)
- Salvatore Facciorusso
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy;
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Gerard E. Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA;
| | - Franco Molteni
- Villa Beretta Rehabilitation Center, Valduce Hospital Como, 23845 Costa Masnaga, Italy;
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
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Wong C. The Relationship between Pain and Spasticity and Tell-Tale Signs of Pain in Children with Cerebral Palsy. Toxins (Basel) 2023; 15:152. [PMID: 36828465 PMCID: PMC9967793 DOI: 10.3390/toxins15020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Pain and quality of life are closely interrelated in children with cerebral palsy (CCP). Even though 67% of CCP experience pain, it is overlooked and untreated. In this study, our purpose was two-fold: first, to examine the relationship between pain and spasticity by evaluating the effects of AbobotulinumtoxinA/Dysport (BoNT), and second, to describe the symptoms and location of pain in CCP. The subjects were 22 CCP in at least moderate pain. They were evaluated for spasticity by the modified Ashworth and Tardieu scale and for pain by the r-FLACC and the pediatric pain profile. After one injection of BoNT, the subjects were re-evaluated. We found a significant reduction in pain, but no significant relationship between the reduction of pain and spasticity. We found no association between the dose of BoNT and pain or spasticity. Pain in the lower extremity was located primarily in the hip region. The effect of ultrasound-guided intermuscular injections of BoNT suggests that pain in CCP has an extra-articular component. We found that pain in CCP manifests as specific tell-tale signs and problems in daily living. In conclusion, we found no relationship between pain and spasticity. Signs and manifestations of pain are described in detail. Lower extremity (hip) pain seems to have a soft tissue/extra-articular component.
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Affiliation(s)
- Christian Wong
- Department of Orthopedic Surgery, University Hospital of Copenhagen, 2650 Hvidovre, Denmark; ; Tel.: +45-35459411
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, 2100 Copenhagen, Denmark
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How does treadmill training contribute to botulinum toxin application plus routine physical therapy in ambulatory children with spastic bilateral cerebral palsy? A randomized controlled trial. Ir J Med Sci 2023; 192:209-217. [PMID: 35224682 DOI: 10.1007/s11845-022-02960-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In spite of treadmill training and multilevel botulinum toxin (BoNT-A) injection being the two most commonly used treatment methods in pediatric rehabilitation management, there was no study investigating the effect of treadmill training after BoNT-A injection in children with cerebral palsy (CP). AIM The aim of this study was to investigate the effect of treadmill training in addition to routine physical therapy after BoNT-A injection in ambulatory children with spastic bilateral CP on lower extremity muscle strength, selective motor control, and mobility. METHODS A total of 30 spastic bilateral children with CP classified level II-III by the Gross Motor Function Classification System were randomly assigned the study and control groups. Both groups continued routine physical therapy treatments after multilevel BoNT-A injection into lower extremities, while the study group additionally underwent 8 weeks of treadmill training (20 min, two sessions per week). Handheld dynamometer, selective control assessment of lower extremity, temporospatial evaluation of gait, and Pediatric Evaluation of Disability Inventory were assessed before and after 8 weeks. RESULTS In both groups, hip, knee, and ankle muscle strength increased at the end of 8 weeks (p < 0.05); however, in the study group, hip flexor/extensor muscle strength (p < 0.05, ES ≥ 0.50), selective motor control of ankle (p < 0.01, ES = 1.17), walking speed (p < 0.01, ES = 2.60), step lengths (p < 0.01, ES = 1.32), and mobility (p < 0.01, ES = 1.37) increased significantly compared to those of the control group. CONCLUSIONS Treadmill training in addition to routine physical therapy after BoNT-A injection is beneficial for hip muscle strength, ankle selective motor control, walking quality, and functional mobility in the short term. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03580174.
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Adverse effects following botulinum toxin A injections in children with cerebral palsy. J Pediatr Orthop B 2023:01202412-990000000-00085. [PMID: 36723611 DOI: 10.1097/bpb.0000000000001055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The study aimed to analyze the adverse events associated with botulinum toxin A (BoNT-A) injections in children with cerebral palsy (CP). The literature search was completed using the Medline, PubMed, Google Scholar, Scopus, and Cochrane Library databases from the earliest date possible up to December 2021. Search terms included 'botulinum toxin', 'cerebral palsy', 'spasticity', 'adverse effects', 'side effects', 'undesirable effects', 'complications', 'lower limb', 'upper limb', and 'children' including combinations of index and free-text terms. Fifty-five studies were included in the study. Data on 6333 pediatric patients and more than 14 080 BoNT-A injections were collected. Respiratory symptoms and respiratory tract infections were the most frequently registered adverse events (AEs). Other common AEs included procedural/focal AEs, flu-like symptoms, and asthenia. Sentinel events including four cases of death were reported. AEs were more frequent and severe in high-dose patients; however, the capacity of BoNT-A to spread systemically remains unclear. Since severe adverse events are not common, further research is needed to collect more definitive clinical and homogeneous data to support the findings of the present research and clarify the safety profile of BoNT-A, especially regarding the incidence of respiratory issues and complications in GMFCS IV or V patients.
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Sutherland E, Hill B, Singer BJ, Ashford S, Hoare B, Hastings-Ison T, Fheodoroff K, Berwick S, Dobson F, Williams G. Do randomised controlled trials evaluating functional outcomes following botulinum neurotoxin-A align with focal spasticity guidelines? A systematic review. Disabil Rehabil 2022; 44:8515-8523. [PMID: 34982603 DOI: 10.1080/09638288.2021.2011437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The impact of botulinum neurotoxin-A (BoNT-A) on functional outcomes when managing focal muscle spasticity remains unclear. It is possible that randomised controlled trial (RCT) design and/or reporting may be a contributing factor. The objective of this review was to determine the extent to which RCTs evaluating functional outcomes following BoNT-A align with focal spasticity guidelines. MATERIALS AND METHODS RCTs published from 2010 were included if they targeted focal spasticity, included BoNT-A, randomised a physical intervention to the upper/lower limb, or the primary outcome(s) related to the activity/participation domains of the International Classification of Functioning, Disability, and Health. Data extraction and quality appraisal using the Modified PEDro and Modified McMasters Tool were performed independently by two reviewers. General research practices were also extracted such as compliance with therapy reporting guidelines. RESULTS Fifty-two RCTs were eligible. Individualised goal setting was uncommon (25%). Six studies (11.5%) included multi-disciplinary management, and five (9.6%) included patient/caregiver education. Four studies (7.7%) measured outcomes beyond 6 months. The Median Modified PEDro score was 11/15. CONCLUSIONS Alignment with focal spasticity guidelines in RCTs was generally low. Our understanding of the impact of focal spasticity management on functional outcomes may be improved if RCT design aligned more closely with guideline recommendations.IMPLICATIONS FOR REHABILITATIONThe influence of BoNT-A on improved functional outcomes is yet to be determined.Individualised goal setting with a multi-disciplinary team is uncommon in an RCT design, despite it being a key guideline recommendation.Given the long-term nature of spasticity management, guidelines recommend short as well as long-term reviews following intervention however RCTs rarely assess beyond 6 months.
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Affiliation(s)
- Edwina Sutherland
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Bridget Hill
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Barby J Singer
- Centre for Training in Subacute Care, WA Health, Fremantle Hospital, Fremantle, Australia.,School of Medical and Health Science, Edith Cowan University, Joondalup, Australia
| | - Stephen Ashford
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.,Centre for Nurse, Midwife and Allied Health Led Research, University College London Hospitals, London, UK.,Faculty of Nursing, Midwifery and Palliative Care, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Brian Hoare
- School of Occupational Therapy, La Trobe University, Bundoora, Australia.,Department of Paediatrics, Monash University, Clayton, Australia
| | - Tandy Hastings-Ison
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Parkville, Australia
| | | | - Steffen Berwick
- Speciality Clinic for Paediatric Neurology, Neurorehabilitation and Epilepsy, Schön Clinic Vogtareuth, Vogtareuth, Germany.,von Hauners' Children's Hospital, Munich University, Munich, Germany
| | - Fiona Dobson
- Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Gavin Williams
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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Peeters N, Papageorgiou E, Hanssen B, De Beukelaer N, Staut L, Degelaen M, Van den Broeck C, Calders P, Feys H, Van Campenhout A, Desloovere K. The Short-Term Impact of Botulinum Neurotoxin-A on Muscle Morphology and Gait in Children with Spastic Cerebral Palsy. Toxins (Basel) 2022; 14:676. [PMID: 36287944 PMCID: PMC9607504 DOI: 10.3390/toxins14100676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 08/27/2023] Open
Abstract
Children with spastic cerebral palsy (SCP) are often treated with intramuscular Botulinum Neurotoxin type-A (BoNT-A). Recent studies demonstrated BoNT-A-induced muscle atrophy and variable effects on gait pathology. This group-matched controlled study in children with SCP compared changes in muscle morphology 8-10 weeks post-BoNT-A treatment (n = 25, median age 6.4 years, GMFCS level I/II/III (14/9/2)) to morphological changes of an untreated control group (n = 20, median age 7.6 years, GMFCS level I/II/III (14/5/1)). Additionally, the effects on gait and spasticity were assessed in all treated children and a subgroup (n = 14), respectively. BoNT-A treatment was applied following an established integrated approach. Gastrocnemius and semitendinosus volume and echogenicity intensity were assessed by 3D-freehand ultrasound, spasticity was quantified through electromyography during passive muscle stretches at different velocities. Ankle and knee kinematics were evaluated by 3D-gait analysis. Medial gastrocnemius (p = 0.018, -5.2%) and semitendinosus muscle volume (p = 0.030, -16.2%) reduced post-BoNT-A, but not in the untreated control group, while echogenicity intensity did not change. Spasticity reduced and ankle gait kinematics significantly improved, combined with limited effects on knee kinematics. This study demonstrated that BoNT-A reduces spasticity and partly improves pathological gait but reduces muscle volume 8-10 weeks post-injections. Close post-BoNT-A follow-up and well-considered treatment selection is advised before BoNT-A application in SCP.
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Affiliation(s)
- Nicky Peeters
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Britta Hanssen
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Lauraine Staut
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Marc Degelaen
- Inkendaal Rehabilitation Hospital, 1602 Vlezenbeek, Belgium
- Rehabilitation Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | | | - Patrick Calders
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | - Hilde Feys
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Anja Van Campenhout
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Orthopedic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Clinical Motion Analysis Laboratory, University Hospitals Leuven, Pellenberg, 3212 Leuven, Belgium
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Akyuz M, Dursun N, Gokbel T, Cekmece C, Dursun E. Improved Sitting Balance in Children with Cerebral Palsy: Body Functions to Activity and Participation. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1749588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractThe aim of this study is to evaluate the changes in activity and participation domains of International Classification of Functioning (ICF), Disability and Health, in children with cerebral palsy (CP) who received integrated botulinum toxin A (BoNT-A) treatment with intensive rehabilitation with a treatment goal of improved sitting balance. In this prospective observational study, 29 patients with CP (mean age: 6.7 ± 3.8 years) and the Gross Motor Function Classification System (GMFCS) levels of IV and V were included. The primary outcome measures were the mean changes from baseline to posttreatment weeks 10 to 12 of the Child and Adolescent Scale of Participation (CASP) and Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD). The modified Ashworth scale (MAS) and Tardieu scale (TS) results at 6 to 8 weeks of posttreatment were the secondary outcome measures. Statistically significant improvements in home and community participation of CASP (p < 0.001 and 0.001), CPCHILD (p < 0.01), MAS (p < 0.001), and all parameters of TS (p < 0.05) were recorded after treatment. The result of this prospective, observational study showed that the functional improvements in sitting balance by the integrated BoNT-A treatment provides positive effects on activity and participation levels of the patient and quality of life of patients and their families.
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Affiliation(s)
- Merve Akyuz
- Department of Physical Medicine and Rehabilitation, Bursa State Hospital, Turkey
| | - Nigar Dursun
- Department of Physical Medicine and Rehabilitation, Kocaeli University Faculty of Medicine, Izmit/Kocaeli, Turkey
| | - Tugba Gokbel
- Department of Physical Medicine and Rehabilitation, Kocaeli University Faculty of Medicine, Izmit/Kocaeli, Turkey
| | - Cigdem Cekmece
- Department of Physical Medicine and Rehabilitation, Kocaeli University Faculty of Medicine, Izmit/Kocaeli, Turkey
| | - Erbil Dursun
- Department of Physical Medicine and Rehabilitation, Kocaeli University Faculty of Medicine, Izmit/Kocaeli, Turkey
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Wong C, Westphall I, Michelsen JS. Measuring Effects on Pain and Quality of Life after Abobotulinum Toxin A Injections in Children with Cerebral Palsy. Toxins (Basel) 2022; 14:43. [PMID: 35051020 PMCID: PMC8781457 DOI: 10.3390/toxins14010043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 01/27/2023] Open
Abstract
Sixty-seven percent of children with cerebral palsy (CCP) experience pain. Pain is closely interrelated to diminished quality of life. Despite this, pain is an overlooked and undertreated clinical problem. The objective of this study was to examine the analgesic effect of a single lower extremity intramuscular injection of Abobotulinum toxin A/Dysport in CCP. Twenty-five CCP with at least moderate pain (r-FLACC ≥ 4) during passive range of motion were included. Localized pain and pain in everyday living were measured by r-FLACC and the Paediatric Pain Profile (PPP), respectively. Functional improvements were evaluated by the goal attainment scale (SMART GAS). Quality of life was evaluated by either the CPCHILD or the CP-QOL. The subjects were evaluated at baseline before injection, then after 4, 12, and 28 weeks. Twenty-two subjects had a significant mean and maximum localized pain reduction (p < 0.001) at four weeks post-treatment in 96% (21/22). The reduction was maintained at 12 (19/19) and 28 weeks (12/15). Daily pain evaluated by the PPP was significantly reduced and functional SMART GAS goals were significantly achieved from 4 to 28 weeks. Quality of life improved significantly at four weeks (CPCHILD). Significant functional gains and localized and daily pain reduction were seen from 4 to 28 weeks.
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Affiliation(s)
- Christian Wong
- Department of Orthopaedic Surgery, Copenhagen University Hospital, 2650 Hvidovre, Denmark
| | - Ian Westphall
- Department of Paediatrics, Copenhagen University Hospital, 2650 Hvidovre, Denmark
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Danchenko N, Johnston KM, Whalen J. The cost-effectiveness of abobotulinumtoxinA (Dysport) and onabotulinumtoxinA (Botox) for managing spasticity of the upper and lower limbs, and cervical dystonia. J Med Econ 2022; 25:919-929. [PMID: 35730362 DOI: 10.1080/13696998.2022.2092354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the costs and benefits associated with the use of abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A) for lower limb spasticity in children, upper and lower limb spasticity in adults, and cervical dystonia in adults. METHODS This pharmacoeconomic analysis compared aboBoNT-A with onaBoNT-A. A decision tree model with a 1-year time horizon was conducted from a UK National Health Service (NHS) perspective using data from a variety of sources: randomized controlled trials (RCTs), network meta-analyses (NMAs), observational studies, and a physician survey investigating treatment patterns and resource utilization. Four patient populations were included: pediatric patients with lower limb spasticity (PLL), and adults with upper limb spasticity (AUL), lower limb spasticity (ALL), and cervical dystonia (CD). Outcomes included costs, quality-adjusted life years (QALYs) gained, cost per responder, and incremental cost per QALY gained. The effectiveness of each treatment was evaluated as a response to treatment. The base case assumption was that all patients in the model continued to receive botulinum toxin type A (BoNT-A) treatments at regular intervals regardless of treatment response status. Scenario analysis evaluated the impact of discontinuing BoNT-A for patients without a response to the first injection. RESULTS The model found that aboBoNT-A resulted in greater quality-of-life and lower costs compared with onaBoNT-A for the management of spasticity and CD in all included indications. Across populations, cost savings ranged from £304 to £3,963 and QALYs gained ranged from 0.010 to 0.02 over a 1-year time horizon. Results were robust to scenario analyses and were driven by the impact of treatment response on health-related quality-of-life. CONCLUSIONS AboBoNT-A was associated with higher treatment response, improved quality-of-life, and reduced costs in spasticity and CD versus onaBoNT-A. These findings could help deliver more effective and efficient healthcare in the NHS.
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Green MM, Kim H, Gauden R, Scheinberg A, Schroeder AS, Heinen F, Berweck S, Hong BY, Gormley M. Needlepoints: Clinical approach to child living with cerebral palsy. J Pediatr Rehabil Med 2022; 15:91-106. [PMID: 35275576 DOI: 10.3233/prm-220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Heakyung Kim
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ruth Gauden
- The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Adam Scheinberg
- The Royal Children's Hospital Melbourne, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia
| | | | | | | | - Bo Young Hong
- St. Vincent's Hospital, Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Mark Gormley
- Gillette Children's Specialty Healthcare, St.Paul, MN, USA
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11
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Kaňovský P, Heinen F, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Martinez-Torres FJ, Pulte I, Banach M, Gaebler-Spira D. Safety and efficacy of repeat long-term incobotulinumtoxinA treatment for lower limb or combined upper/lower limb spasticity in children with cerebral palsy. J Pediatr Rehabil Med 2022; 15:113-127. [PMID: 34957963 PMCID: PMC9028655 DOI: 10.3233/prm-210041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The open-label phase 3 "Treatment with IncobotulinumtoxinA in Movement Open-Label" (TIMO) study investigated longer-term safety and efficacy of incobotulinumtoxin A in children/adolescents with cerebral palsy (CP). METHODS Patients on standard treatment, with unilateral or bilateral lower limb (LL) or combined upper limb (UL)/LL spasticity received four incobotulinumtoxinA injection cycles (16 or 20 Units/kg bodyweight total [maximum 400 or 500 Units] per cycle depending on ambulatory status/clinical pattern treated), each followed by 12-16 weeks' observation. Treatment for pes equinus was mandatory; flexed knee or adducted thigh were options for unilateral treatment and/or ULs for unilateral/bilateral treatment. The primary endpoint was safety; changes in Ashworth Scale and Gross Motor Function Measure-66 scores, and Global Impression of Change Scale scores at week 4 of each injection cycle were also evaluated. RESULTS IncobotulinumtoxinA (≤500 Units for ≤98 weeks) was safe, well-tolerated, and effective across all endpoints for multipattern treatment of LL and combined LL/UL spasticity in ambulant/nonambulant children/adolescents with CP. Treatment effects increased with each injection cycle. No new/unexpected safety concerns were identified. CONCLUSION IncobotulinumtoxinA showed a good safety and tolerability profile, with efficacy over multiple clinical presentations. As an adjunct treatment, it offers an effective, individualized treatment option for pediatric CP-related spasticity.
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Affiliation(s)
- Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Florian Heinen
- Department of Pediatric Neurology & Developmental Medicine and LMU Center for Children with Medical Complexity, Dr.von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - A Sebastian Schroeder
- Department of Pediatric Neurology & Developmental Medicine and LMU Center for Children with Medical Complexity, Dr.von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, MI, USA
| | | | | | | | - Irena Pulte
- Merz Pharmaceuticals Gmb H, Frankfurt am Main, Germany
| | - Marta Banach
- Department of Neurology, Collegium Medicum, Jagiellonian University, Krakow, Poland
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Dimitrova R, Kim H, Meilahn J, Chambers HG, Racette BA, Bonikowski M, Park ES, McCusker E, Liu C, Brin MF. Efficacy and safety of onabotulinumtoxinA with standardized physiotherapy for the treatment of pediatric lower limb spasticity: A randomized, placebo-controlled, phase III clinical trial. NeuroRehabilitation 2021; 50:33-46. [PMID: 34957954 PMCID: PMC8925123 DOI: 10.3233/nre-210070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Spasticity is common in cerebral palsy and can result in pain and diminished health-related quality of life. OBJECTIVE: To evaluate the safety and efficacy of onabotulinumtoxinA for lower limb spasticity treatment in children with cerebral palsy. METHODS: In this registrational phase 3, multinational, randomized, double-blind, placebo-controlled trial (NCT01603628), children (2–< 17 years) with cerebral palsy and ankle spasticity (Modified Ashworth Scale-Bohannon [MAS] score≥2) were randomized 1 : 1 : 1 to standardized physical therapy and onabotulinumtoxinA (4 or 8 U/kg), or placebo. Primary endpoint was average change from baseline at weeks 4 and 6 in MAS ankle score. Secondary endpoints included the Modified Tardieu Scale (MTS) and Global Attainment Scale (GAS). RESULTS: 381 participants were randomized. MAS scores averaged at weeks 4 and 6 were significantly reduced with both onabotulinumtoxinA doses (8 U/kg: –1.06, p = 0.010; 4 U/kg: –1.01, p = 0.033) versus placebo (–0.8). Significant improvements in average dynamic component of spasticity, measured by MTS, and in function, measured by GAS, were observed at several time points with both onabotulinumtoxinA doses versus placebo. Most adverse events were mild or moderate. CONCLUSIONS: OnabotulinumtoxinA was well tolerated and effective in reducing lower limb spasticity and improving functional outcomes versus placebo in children.
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Affiliation(s)
| | - Heakyung Kim
- Columbia University Medical Center, New York, NY, USA
| | - Jill Meilahn
- Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Brad A Racette
- Washington University School of Medicine, St. Louis, MO, USA.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown, SouthAfrica
| | | | | | | | | | - Mitchell F Brin
- Allergan, an AbbVie company, Irvine, CA, USA.,University of California, Irvine, CA, USA
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13
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Oleszek J, Tilton A, Carranza Del Rio J, Dursun N, Bonikowski M, Dabrowski E, Page S, Regnault B, Thompson C, Delgado MR. Muscle Selection and Dosing in a Phase 3, Pivotal Study of AbobotulinumtoxinA Injection in Upper Limb Muscles in Children With Cerebral Palsy. Front Neurol 2021; 12:728615. [PMID: 34803878 PMCID: PMC8603760 DOI: 10.3389/fneur.2021.728615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Guidelines recommend botulinum toxin-A in pediatric upper limb spasticity as part of routine practice. Appropriate dosing is a prerequisite for treatment success and it is important that injectors have an understanding on how to tailor dosing within a safe and effective range. We report upper limb dosing data from a phase 3 study of abobotulinumtoxinA injections in children with cerebral palsy. Methods: This was a double-blind, repeat-treatment study (NCT02106351). In Cycle 1, children were randomized to abobotulinumtoxinA at 2 U/kg control dose or clinically relevant 8 U/kg or 16 U/kg doses. Doses were divided between the primary target muscle group (PTMG, wrist or elbow flexors) and additional muscles tailored to clinical presentation. During Cycles 2–4, children received doses of 8 U/kg or 16 U/kg and investigators could change the PTMG and other muscles to be injected. Injection of muscles in the other upper limb and lower limbs was also permitted in cycles 2–4, with the total body dose not to exceed 30 U/kg or 1,000 U (whichever was lower) in the case of upper and lower limb treatment. Results: 212 children were randomized, of which 210 received ≥1 abobotulinumtoxinA injection. Per protocol, the elbow and wrist flexors were the most commonly injected upper limb muscles. Across all 4 cycles, the brachialis was injected in 89.5% of children (dose range 0.8–6 U/kg), the brachioradialis in 83.8% (0.4–3 U/kg), the flexor carpi ulnaris in 82.4% (0.5–3 U/kg) and the flexor carpi radialis in 79.5% (0.5–4 U/kg). Other frequently injected upper limb muscles were the pronator teres(70.0%, 0.3–3 U/kg). adductor pollicis (54.3%, 0.3-1 U/kg), pronator quadratus (44.8%, 0.1–2 U/kg), flexor digitorum superficialis (39.0%, 0.5-4 U/kg), flexor digitorum profundus (28.6%, 0.5–2 U), flexor pollicis brevis/opponens pollicis (27.6%, 0.3-1 U/kg) and biceps (27.1%, 0.5–6 U/kg). AbobotulinumtoxinA was well-tolerated at these doses; muscular weakness was reported in 4.3% of children in the 8 U/kg group and 5.7% in the 16 U/kg group. Conclusions: These data provide information on the pattern of injected muscles and dose ranges used in this study, which were well-tolerated. Per protocol, most children received injections into the elbow and wrist flexors. However, there was a wide variety of other upper limb muscles injected as physicians tailored injection patterns to clinical need.
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Affiliation(s)
- Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, University of Colorado and Children's Hospital Colorado, Aurora, IL, United States
| | - Ann Tilton
- LSUHSC and Children's Hospital New Orleans, New Orleans, LA, United States
| | | | - Nigar Dursun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kocaeli University, Izmit, Turkey
| | | | - Edward Dabrowski
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI, United States
| | | | | | | | - Mauricio R Delgado
- Southwestern Medical Center, Scottish Rite Hospital for Children, University of Texas, Dallas, TX, United States
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Dabrowski E, Chambers HG, Gaebler-Spira D, Banach M, Kaňovský P, Dersch H, Althaus M, Geister TL, Heinen F. IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial. Pediatr Neurol 2021; 123:10-20. [PMID: 34339951 DOI: 10.1016/j.pediatrneurol.2021.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/07/2021] [Accepted: 05/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment. METHODS Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs). RESULTS AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels. CONCLUSIONS Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.
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Affiliation(s)
- Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, Michigan.
| | | | | | - Marta Banach
- Department of Neurology, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Hanna Dersch
- Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | | | | | - Florian Heinen
- LMU Klinikum Munich, Division of Pediatric Neurology & LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
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15
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Delgado MR, Tilton A, Carranza‐Del Río J, Dursun N, Bonikowski M, Aydin R, Maciag‐Tymecka I, Oleszek J, Dabrowski E, Grandoulier A, Picaut P. Efficacy and safety of abobotulinumtoxinA for upper limb spasticity in children with cerebral palsy: a randomized repeat-treatment study. Dev Med Child Neurol 2021; 63:592-600. [PMID: 33206382 PMCID: PMC8048784 DOI: 10.1111/dmcn.14733] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
AIM To assess the efficacy and safety of repeat abobotulinumtoxinA injections in reducing upper limb spasticity in children with cerebral palsy (CP). METHOD This was a double-blind, repeat-cycle study (NCT02106351) in children with CP (2-17y). Children were randomized to receive 2U/kg (control), 8U/kg, or 16U/kg abobotulinumtoxinA injections into the target muscle group (wrist or elbow flexors) and additional muscles alongside occupational therapy via a home-exercise therapy program (HETP; minimum five 15min sessions/wk). Children received 8U/kg or 16U/kg plus HETP in cycles 2 to 4. RESULTS During cycle 1, 210 children (126 males, 84 females; mean age [SD] 9y [4y 5mo], range 2-17y; n=70/group) had at least one upper limb abobotulinumtoxinA injection and 209 complied with the HETP. At week 6 of cycle 1, children in the 8U/kg or 16U/kg groups had significantly lower Modified Ashworth scale scores versus the 2U/kg group (primary outcome: treatment differences of -0.4 [p=0.012] and -0.7 [p<0.001] respectively). All groups improved on Physician Global Assessment and children in all groups achieved their treatment goals at least as expected. Therapeutic benefits were sustained during cycles 2 to 4; muscular weakness was the only treatment-related adverse event reported in at least one child/group (4.3% and 5.7% vs 1.4% respectively). INTERPRETATION Treatment with 8U/kg or 16U/kg abobotulinumtoxinA significantly reduced upper limb spasticity versus the 2U/kg control dose. Therapeutic benefits of abobotulinumtoxinA plus HETP were sustained with repeat treatment cycles. WHAT THIS PAPER ADDS AbobotulinumtoxinA injections significantly reduced upper limb spasticity in children with cerebral palsy. Children treated with abobotulinumtoxinA and targeted home exercises showed global improvement and goal attainment. Benefits were sustained over 1 year with repeat cycles of abobotulinumtoxinA and home exercises. AbobotulinumtoxinA injections into the upper limb were well tolerated over 1 year.
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Affiliation(s)
- Mauricio R Delgado
- Department of NeurologyUniversity of Texas Southwestern Medical CenterScottish Rite Hospital for ChildrenDallasTXUSA
| | - Ann Tilton
- Department of NeurologyLSUHSC and Children's Hospital New OrleansNew OrleansLAUSA
| | | | - Nigar Dursun
- Department of Physical Medicine and RehabilitationFaculty of MedicineKocaeli UniversityKocaeliTurkey
| | | | - Resa Aydin
- Department of Physical Medicine and RehabilitationIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | | | - Joyce Oleszek
- Department of Physical Medicine and RehabilitationUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Edward Dabrowski
- Department of Pediatric Physical Medicine and RehabilitationBeaumont HealthOakland University School of MedicineGrosse PointeMIUSA
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16
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Kurenkov AL, Klochkova OA, Kuzenkova LM, Bursagova BI, Karimova KM. [Multilevel botulinum toxin treatment in severe spastic forms of cerebral palsy (GMFCS IV-V)]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 120:57-66. [PMID: 33459542 DOI: 10.17116/jnevro202012012157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the most typical target muscles and dosages for the first and repeated botulinum toxin A (BTA) injections in cerebral palsy (CP) patients with severe motor deficit - GMFCS IV-V. MATERIAL AND METHODS A retrospective analysis of 677 protocols of the first and repeated Abobotulinumtoxin A (AboA) injections in 333 patients with CP GMFCS IV and V, aged 1 to 18 years, was carried out. RESULTS Ninety-seven percent of patients received multilevel injections. In the lower extremities the most typical target muscles were: m.gracilis - 221 (66.4%) patients, hip adductors - 164 (49.2%), medial hamstring - 144 (43.2%). In the upper extremities the most typical muscles were: m.pronator teres - 237 (71.2%) patients, m.biceps brachii+m.brachialis - 197 (59.2%). The total dosages of AboA and dosages for every target muscle were calculated. Several patients required high dosages (more than 30 U/kg of AboA). Higher dosages per kg were used in younger children and for repeated injections. The age-related evolution of spastic patterns was described. Adverse events were observed in 36 cases (5.3% of all injections). CONCLUSION The majority of patients with GMFCS IV-V required multilevel BTA injections in high dosages, especially in young age. Described selection of target muscles and dosages of AboA could be taken into account as a practical experience and reference for the BTA therapy in GMFCS IV-V patients.
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Affiliation(s)
- A L Kurenkov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O A Klochkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - L M Kuzenkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - B I Bursagova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - Kh M Karimova
- National Medical Research Center for Children's Health, Moscow, Russia
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17
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Heinen F, Kanovský P, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Martinez-Torres FJ, Pulte I, Banach M, Gaebler-Spira D. IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study. J Pediatr Rehabil Med 2021; 14:183-197. [PMID: 34092664 PMCID: PMC8673523 DOI: 10.3233/prm-210040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity. METHODS Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System - Expanded and Revised I-V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ⩾ 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh. ENDPOINTS Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator's, patient's, and parent's/caregiver's GICS, Gross Motor Function Measure-66 (GMFM-66). RESULTS Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development. CONCLUSION Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.
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Affiliation(s)
- Florian Heinen
- Dr. von Hauner Children's Hospital, LMU - University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | - Petr Kanovský
- Palacký University Olomouc and University Hospital, Olomouc, Czech Republic
| | - A Sebastian Schroeder
- Dr. von Hauner Children's Hospital, LMU - University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | | | - Edward Dabrowski
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI, USA
| | | | | | | | - Irena Pulte
- Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
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18
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Deputy SR, Tilton AH. Treatment of Disorders of Tone and Other Considerations in Pediatric Movement Disorders. Neurotherapeutics 2020; 17:1713-1723. [PMID: 33410106 PMCID: PMC7851300 DOI: 10.1007/s13311-020-00984-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/26/2022] Open
Abstract
Pediatric movement disorders (PMDs) consist of a heterogeneous group of signs and symptoms caused by numerous neurological diseases. Different neurological disorders in children also share overlapping movement disorders making a diagnosis of the underlying cause of the movement disorder challenging. The similarity of the symptoms across multiple disease types suggests that there may be a final common motor pathway causing the overlapping movement disorders. There are numerous disorders in children associated with disturbances in tone and involuntary movements. This chapter will focus primarily on those disorders that involve abnormalities of tone and other important considerations of pediatric movement disorders. This chapter will address rating scales and goals for treatment and will include a review of symptomatic treatment and, where possible, the treatment of the underlying disease processes. The chapter will review representative disorders, including an inborn error of metabolism, an autoimmune disorder, and a group of neurodegenerative disorders. These examples demonstrate how the disorder's underlying pathophysiology results in a specific approach to the underlying disease and the associated conditions of tone and involuntary movements. Finally, the multiple treatment options for cerebral palsy and considerations of cerebral palsy mimics will be discussed.
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Affiliation(s)
- Stephen R Deputy
- Department of Neurology, Division of Child Neurology, Louisiana State University Health Sciences Center at New Orleans, Children's Hospital, 200 Henry Clay Ave., New Orleans, LA, 70118, USA
| | - Ann H Tilton
- Department of Neurology, Division of Child Neurology, Louisiana State University Health Sciences Center at New Orleans, Children's Hospital, 200 Henry Clay Ave., New Orleans, LA, 70118, USA.
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19
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Esquenazi A, Delgado MR, Hauser RA, Picaut P, Foster K, Lysandropoulos A, Gracies JM. Duration of Symptom Relief Between Injections for AbobotulinumtoxinA (Dysport®) in Spastic Paresis and Cervical Dystonia: Comparison of Evidence From Clinical Studies. Front Neurol 2020; 11:576117. [PMID: 33101184 PMCID: PMC7546809 DOI: 10.3389/fneur.2020.576117] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/12/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Botulinum toxin-A is a well-established treatment for adult and pediatric spastic paresis and cervical dystonia. While guidelines and approved labels indicate that treatment should not occur more frequently than every 12 weeks, studies and real-world evidence show that the timing of symptom recurrence between treatments may vary. Methods: We report retreatment criteria and response duration (retreatment intervals) from four pivotal, double-blind, placebo-controlled studies with open-label extensions involving patients treated with abobotulinumtoxinA (aboBoNTA) for upper limb (NCT01313299) or lower limb (NCT01249404) spastic paresis in adults, lower limb spastic paresis in children (NCT01249417), and cervical dystonia in adults (NCT00257660). We review results in light of recently available preclinical data. Results: In spastic paresis, 24.0-36.9% of upper limb patients treated with aboBoNTA and 20.1-32.0% of lower limb patients did not require retreatment before 16 weeks. Moreover, 72.8-93.8% of aboBoNTA-treated pediatric patients with lower limb spastic paresis did not require retreatment before 16 weeks (17.7-54.0% did not require retreatment before 28 weeks). In aboBoNTA-treated patients with cervical dystonia, 72.6-81.5% did not require retreatment before 16 weeks. Conclusion: AboBoNTA, when dosed as recommended, offers symptom relief beyond 12 weeks to many patients with spastic paresis and cervical dystonia. From recently available preclinical research, the amount of active neurotoxin administered with aboBoNTA might be a factor in explaining this long duration of response.
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Affiliation(s)
- Alberto Esquenazi
- Department of Physical Medicine and Rehabilitation, MossRehab Gait and Motion Analysis Laboratory, Elkins Park, PA, United States
| | - Mauricio R Delgado
- Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, United States
| | - Robert A Hauser
- University of South Florida Parkinson's Disease and Movement Disorders Center of Excellence, Tampa, FL, United States
| | | | | | | | - Jean-Michel Gracies
- UR 7377, Université Paris-Est Créteil, Service de Rééducation Neurolocomotrice, Albert Chenevier-Henri Mondor Hospital, Créteil, France
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20
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Reilly M, Liuzzo K, Blackmer AB. Pharmacological Management of Spasticity in Children With Cerebral Palsy. J Pediatr Health Care 2020; 34:495-509. [PMID: 32861428 DOI: 10.1016/j.pedhc.2020.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/02/2020] [Accepted: 04/20/2020] [Indexed: 11/16/2022]
Abstract
Cerebral palsy (CP), a nonprogressive disease of the central nervous system, is the most common motor disability in childhood. Patients with CP often have a multitude of associated comorbidities, including impact on muscle tone. There are four main types of CP, with spastic as the most commonly diagnosed. Reduction in spasticity is important because it can affect not only the patient's quality of life, functional abilities, and well-being but also the lives of caregivers. The American Academy of Neurology and Child Neurology Society released a practice parameter regarding the pharmacological management of CP-related spasticity in 2010. Since then, data have been published evaluating the safety and efficacy of oral and parenteral medications to manage spasticity. This continuing education review evaluates the available safety and efficacy evidence for oral and parenteral pharmacological agents used to reduce spasticity in children with CP and provides a reference for practitioners managing these patients.
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21
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Dursun N, Bonikowski M, Dabrowski E, Matthews D, Gormley M, Tilton A, Carranza J, Grandoulier AS, Picaut P, Delgado MR. Efficacy of Repeat AbobotulinumtoxinA (Dysport®) Injections in Improving Gait in Children with Spastic Cerebral Palsy. Dev Neurorehabil 2020; 23:368-374. [PMID: 31691605 DOI: 10.1080/17518423.2019.1687602] [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] [Indexed: 10/25/2022]
Abstract
Purpose: This secondary analysis of a randomized, double-blind study plus open-label extension (NCT01249417/NCT01251380) evaluated the efficacy of abobotulinumtoxinA versus placebo in improving gait pattern in children with dynamic equinus due to cerebral palsy (CP) as assessed by the observational gait scale (OGS). Methods: Ambulatory children with CP (N = 241, aged 2-17) and dynamic equinus were randomized to treatment with abobotulinumtoxinA (10 or 15U/kg/leg) or placebo injected into the gastrocsoleus. All children received abobotulinumtoxinA in the open-label phase. Results: In the double-blind phase, abobotulinumtoxinA significantly improved OGS total scores versus placebo at Week 4 (treatment effect vs. placebo: 10U/kg/leg: 1.5 [0.7, 2.3], p = .0003; 15U/kg/leg: 1.1 [0.3, 1.9], p = .01). In the open-label phase, treatment with abobotulinumtoxinA continued to improve the OGS score at the same magnitude as seen in the double-blind study. Conclusion: Repeat treatment with abobotulinumtoxinA improved gait in children with dynamic equinus.
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Affiliation(s)
| | | | | | | | - Mark Gormley
- Gillette Children's Speciality Healthcare , St Paul, MN, USA
| | - Ann Tilton
- LSUHSC and Children's Hospital New Orleans , New Orleans, LA, USA
| | | | | | | | - Mauricio R Delgado
- University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children , Dallas, TX, USA
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22
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Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
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Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
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23
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Abstract
Identifying the subtypes of hypertonia is becoming increasingly important. Treatment strategies, including tone-modulating surgical interventions, medication type and dosing, and chemodenervation, may differ depending on the type of hypertonia present. It is important to delineate how hypertonia interferes with function and quality of life so that the appropriate intervention can be selected at the right time. Outcomes of treatment depend heavily on clear communication of goals. Botulinum toxin should not be used in isolation but as an adjunct to rehabilitation modalities.
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Affiliation(s)
- Rochelle Dy
- PM&R, Texas Children's Hospital, 6701 Fannin Street, Suite D1280, Houston, TX 77030, USA.
| | - Desiree Roge
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Johnston K, Danchenko N, Hansen R, Dinet J, Liovas A, Armstrong A, Bains S, Sullivan SD. Cost effectiveness and impact on quality of life of abobotulinumtoxinA and onabotulinumtoxinA in the treatment of children with lower limb spasticity in Canada. J Med Econ 2020; 23:631-640. [PMID: 31985313 DOI: 10.1080/13696998.2020.1722138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Injectable botulinum neurotoxins are a mainstay of treatment for pediatric spasticity. AbobotulinumtoxinA and onabotulinumtoxinA are both injectable toxin therapies used to treat pediatric lower limb (PLL) spasticity in Canada. The objective of this study was to assess the cost-effectiveness of abobotulinumtoxinA vs. onabotulinumtoxinA in the treatment of PLL spasticity in Canada.Methods: A probabilistic Markov cohort model with a 2-year time horizon was developed, with health states defined by response to therapy, as characterized by the goal attainment scale (GAS). Based on randomized controlled trial evidence, response to therapy was similar or higher for abobotulinumtoxinA relative to onabotulinumtoxinA; uncertainty was incorporated into model parameters, however, as the two therapies have not been compared head-to-head. Canadian resource use and cost data were incorporated.Results: In the base case, abobotulinumtoxinA generated 1.48 quality-adjusted life years over the model time horizon, compared to 1.47 for onabotulinumtoxinA. AbobotulinumtoxinA was associated with cost savings of $123 CAD, reflecting lower costs in both medication acquisition and health services. The estimated improvement to quality of life and reduced costs result in an estimate of economic dominance for abobotulinumtoxinA over onabotulinumtoxinA. This dominant result persisted across probabilistic and scenario analyses.Key points for decision makersBased on a review of available clinical evidence, abobotulinumtoxinA was found to have significant and/or numerical efficacy benefits to onabotulinumtoxinA on functional outcomes (Goal Attainment Scale) and tone (Modified Ashworth Scale) and in the treatment of pediatric lower limb spasticityIn this cost-effectiveness analysis, abobotulinumtoxinA was found to be associated with greater quality-adjusted life years and lower costs than onabotulinumtoxinA (economically dominant)A limitation of this analysis was the uncertainty around key parameters. Specifically, the lack of head-to-head comparison data for the two therapies, and variable data regarding likely onabotulinumtoxinA dosing in PLL in clinical practice. However, across a range of plausible scenarios, the economic dominant result remained.
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Affiliation(s)
- Karissa Johnston
- Broadstreet Health Economics and Outcomes Research, Vancouver, Canada
| | | | - Ryan Hansen
- Choice Institute, University of Washington, Seattle, WA, USA
| | - Jerome Dinet
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | - Anna Liovas
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | - Ava Armstrong
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | | | - Sean D Sullivan
- Choice Institute, University of Washington, Seattle, WA, USA
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Fathi M, Hussein AS, M Elghazaly S, Al-Kinawy AM, Abdeltawab AK, Mansour YM, Elbehbeh NA, Sherif A, Afifi AM. Effect of Botulinum Toxin on Equinus Foot Deformity in Cerebral Palsy Patients: A Systematic Review and Network Meta-analysis. Curr Pharm Des 2020; 26:4796-4807. [PMID: 32418518 DOI: 10.2174/1381612826666200518105633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is a brain disorder that affects the development, movement and posture leading to limitation of Range of Movement (ROM) in the growing children. CP leads to deformities such as equinus foot deformity. We aim to investigate the efficacy of different botulinum toxin (BTX) products with or without serial casting in reducing the muscle spasticity in equinus foot deformity in patients with CP. METHODS A systematic review of the literature was performed by searching different electronic databases. Pub- Med, Scopus, Web of Science (WOS), and GHL databases were used. We analyzed the extracted data by network meta-analysis method using the R software package (version 3.5.0). RESULTS Regarding Modified Ashworth score (MAS), BTX-A was superior compared to placebo and BTX-A plus immediate casting (MD = -0.39, 95% CI [-0.60; -0.18]) and (MD = -0.50, 95% CI [-0.98; -0.02]), respectively. Concerning growth motor function movement Classification System (GMFM), Neuronox ranked above at 3 months (MD = -1.60, 95% CI [-2.87; -0.33]) and at six months (MD = -1.90, 95% CI [-3.48; -0.32]) compared to BTX-A. Regarding the Modified Tardieu scale (MTS) with knee flexion, BTX-A was superior to BTX-A plus immediate casting (MD = 8.60, 95% CI [1.76; 15.44]). Concerning passive range of movement (PROM) with Knee flexion or extension at 3 months, BTX-A showed a significant improvement compared to BTX-A plus immediate casting. CONCLUSION BTX-A ranked best on a physician rating scale (PRS), MAS, MTS with knee flexion and PROM (Knee flexion and extension) compared to Neuronox and Botulax. BTX-A alone was also better than BTX-A plus immediate casting.
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Affiliation(s)
| | | | | | | | | | | | | | - Ahmed Sherif
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed M Afifi
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Khatkova SE, Kostenko EV, Akulov MA, Diagileva VP, Nikolaev EA, Orlova AS. [Modern aspects of the pathophysiology of walking disorders and their rehabilitation in post-stroke patients]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 119:43-50. [PMID: 32207717 DOI: 10.17116/jnevro201911912243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The problem of rehabilitation of post-stroke patients with motor deficit remains relevant with growing prevalence of disability and decreasing mortality, despite all measures aimed at stroke prevention and morbidity reduction. One of the most common consequences of stroke is gait impairment as a result of spastic paresis of the lower limb (decreased gait velocity, shortened step, excessive loading of intact limb etc.), which leads to significant maladaptation, increased risk of falls, decrease in quality of life. The article presents a detailed review of motor action in normal and pathologic conditions, analysis of neuronal structures involved into a movement act in healthy individuals and in stroke patients, current aspects of gait pathophysiology, characteristics of post-stroke gait (speed and asymmetry of gain, balance control impairment). A separate paragraph is devoted to gait recovery after stroke with analysis of existing and developing strategies of rehabilitation, aimed at the improvement of vertical posture, balance control and movement, condition, tone and functioning of skeletal muscles. Authors also analyze new research information on the efficacy of botulinum toxin preparations and programs of Guided Self-Rehabilitation Contracts (GSC), present the results of clinical trials demonstrating the efficacy of combination of these two methods.
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Affiliation(s)
- S E Khatkova
- Medical and Rehabilitation Center, Moscow, Russia; State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - E V Kostenko
- Burdenko National Scientific and Practical Centre for Neurosurgery, Moscow, Russia
| | - M A Akulov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V P Diagileva
- Medical and Rehabilitation Center, Moscow, Russia; State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - E A Nikolaev
- Medical and Rehabilitation Center, Moscow, Russia; State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - A S Orlova
- Sechenov First Moscow State Medical University, Moscow, Russia
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Valentine J, Davidson SA, Bear N, Blair E, Paterson L, Ward R, Forbes D, Elliott C. A prospective study investigating gross motor function of children with cerebral palsy and GMFCS level II after long-term Botulinum toxin type A use. BMC Pediatr 2020; 20:7. [PMID: 31906902 PMCID: PMC6945782 DOI: 10.1186/s12887-019-1906-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to contribute to the knowledge base on the long-term outcomes of evidence-based medical interventions used to improve gross motor function in children and adolescents with Cerebral Palsy. METHOD Prospective cohort study of children with Cerebral Palsy in the birth years 2000-2009 attending a tertiary level service for children with Cerebral Palsy who's first recorded Gross Motor Function Classification System level was II. RESULTS A total of 40 children were eligible for the study, of whom 28 (72.7%) enrolled. The Botulinum toxin A treatment for this cohort, (median and interquartile ranges) were: total number of lower limb Botulinum toxin A injections 11 (6.7, 5.5); total dose of Botulinum Toxin A per lower limb treatment 6.95 u/kg (4.5, 11); and dose of Botulinum Toxin u/kg/muscle 2.95 (2.2, 4). For all 28 subjects there was a median of 15 (8.5 to 22) Gross Motor Function Classification System level recordings: six of the 28 children (21.4%) improved from level II to level I, the remaining 22 children remained stable at level II (78.6%). In this highly treated population, the average 66 item Gross Motor Function Measure score for the 22 children in level II was 72.55, which is consistent with the mean of 68.5 reported in the original Ontario cohort. CONCLUSION This cohort study has confirmed that children with Cerebral Palsy, Gross Motor Function level II treated at a young age with repeated doses of Botulinum Toxin A within an integrated comprehensive service, maintain or improve their functional motor level at a later age.
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Affiliation(s)
- Jane Valentine
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia. .,Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia.
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Nedlands, Western Australia, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Lisa Paterson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| | - David Forbes
- School of Medicine, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia
| | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
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Kovalenko AP, Misikov VK, Iskra DA, Koshkarev MA, Sinelnikov KA. [Tardue scales in the diagnostic of spasticity]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:83-90. [PMID: 31626223 DOI: 10.17116/jnevro201911909183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Diagnosis, treatment and rehabilitation of patients with spasticity remain a challenge, in which standard methodological approaches have not yet been developed. One of the most promising solutions to this problem is the use of the Modified Tardieu scale (MTS). The article describes the method of working with MTS tested in the examination, treatment and rehabilitation of patients with acute cerebrovascular accident (n=112) and patients with multiple sclerosis (n=17). The original version of MTS has been translated into Russian. The use of MTS assessment system allows the diagnosis of the main elements of the clinical picture of the damage to the central nervous system, such as paresis, spasticity, violation of proprioception, as well as the qualitative and quantitative assessment of the dynamics of rehabilitation and treatment of spasticity with botulinum neurotoxin (BoNT).
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Affiliation(s)
- A P Kovalenko
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - V K Misikov
- Vladimirsky Moscow Region Research and Clinical Institute, Moscow, Russia
| | - D A Iskra
- Kirov Military Medical Academy, St. Petersburg, Russia
| | | | - K A Sinelnikov
- Central Military Clinical Hospital, Sergiev Posad, Russia ,Pokrovskaya City Hospital, St. Petersburg, Russia
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Blumetti FC, Belloti JC, Tamaoki MJS, Pinto JA. Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy. Cochrane Database Syst Rev 2019; 10:CD001408. [PMID: 31591703 PMCID: PMC6779591 DOI: 10.1002/14651858.cd001408.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is the most common cause of physical disabilities in children in high-income countries. Spasticity is the most common motor disturbance in CP. Botulinum toxin type A (BoNT-A) is considered the first-line treatment for focal spasticity in people with CP. OBJECTIVES To evaluate the effectiveness and safety of BoNT-A compared to other treatments used in the management of lower limb spasticity in children with CP. SEARCH METHODS We searched CENTRAL, PubMed, four other databases, and two trial registers in October 2018. We also searched the reference lists of relevant studies and reviews and contacted experts in the field. We did not apply any date or language restrictions. SELECTION CRITERIA Randomised controlled trials of children with CP, aged between birth and 19 years, treated with BoNT-A injections in the lower limb muscles compared to other interventions. The primary outcomes were gait analysis and function. The secondary outcomes were joint range of motion, quality of life, satisfaction, spasticity, and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data, assessed risk of bias, and rated the quality of the evidence using GRADE. A third review author arbitrated in case of disagreements. We conducted meta-analyses of available data whenever possible, analysing dichotomous data with risk ratios (RR), and continuous data with mean differences (MD) or standardised mean differences (SMD), with 95% confidence intervals (CI). We considered a 5% significance level for all analyses.Whenever possible, we analysed outcomes at the time points at which they were assessed: short term (2 to 8 weeks); medium term (12 to 16 weeks); and long term (> 24 weeks). MAIN RESULTS We included 31 randomised controlled trials assessing 1508 participants. Most studies included ambulatory patients with more than one motor type of CP, and with a mean age of between three and seven years. There was a slight predominance of males.Studies compared BoNT-A in the lower limb muscles to usual care or physiotherapy (14 studies), placebo or sham (12 studies), serial casting (4 studies), or orthoses (1 study).We rated studies as at high or unclear risk of bias mainly due to random sequence generation, allocation concealment, blinding of participants and personnel, and blinding of outcome assessment.BoNT-A versus usual care or physiotherapyBoNT-A might improve overall gait scores at medium-term follow-up (MD 2.80, 95% CI 1.55 to 4.05; 1 study, 40 children; very low-quality evidence) and is moderately effective at improving function at short-term (SMD 0.59, 95% CI 0.23 to 0.95; 2 studies, 123 children) and medium-term (SMD 1.04, 95% CI 0.16 to 1.91; 4 studies, 191 children) follow-up (all very low-quality evidence).BoNT-A improves ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (very low-quality evidence).The proportion of adverse events in the BoNT-A group was 0.37 (95% CI 0.08 to 0.66; I2 = 95%; very low-quality evidence). No adverse events were reported in the control group.BoNT-A versus placebo or shamBoNT-A improves overall gait scores at short-term (RR 1.66, 95% CI 1.16 to 2.37, P = 0.006; 4 studies, 261 assessments) and medium-term (RR 1.90, 95% CI 1.32 to 2.74, P < 0.001; 3 studies, 248 assessments) follow-up, and may improve peak ankle dorsiflexion in stance (MD 15.90 degrees, 95% CI 4.87 to 26.93, P = 0.005; 1 study, 19 children) and in swing (MD 10.20 degrees, 95% CI 4.01 to 16.39, P = 0.001; 1 study, 19 children) at short-term follow-up (all moderate-quality evidence).BoNT-A is not more effective than placebo or sham at improving function at short-term (SMD 0.24, 95% CI -0.35 to 0.83, P = 0.42; 4 studies, 305 children) or long-term (SMD -0.07, 95% CI -0.48 to 0.35, P = 0.76; 2 studies, 91 children) follow-up, but has a small positive effect at medium-term follow-up (SMD 0.28, 95% CI 0.06 to 0.49, P = 0.01; 5 studies, 327 children) (all moderate-quality evidence).BoNT-A improves passive ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (moderate-quality evidence).There was no difference between groups in the rate of adverse events at short-term follow-up (RR 1.29, 95% CI 0.87 to 1.93, P = 0.21; 12 studies, 918 children; moderate-quality evidence).BoNT-A versus serial castingThere was no difference between groups for overall gait scores at short-term (MD 0.00, 95% CI -1.66 to 1.66); medium-term (MD 0.65, 95% CI -1.21 to 2.51); or long-term (MD 0.46, 95% CI -1.33 to 2.25) follow-up in one study with 18 children (moderate-quality evidence).BoNT-A improved instrumented gait analysis only in terms of ankle dorsiflexion at initial contact (MD 6.59 degrees, 95% CI 1.39 to 11.78, P = 0.01; 2 studies, 47 children). There was no difference between groups for peak ankle dorsiflexion in stance and swing, and gait speed at any time point (moderate- and low-quality evidence).BoNT-A is not more effective than serial casting at improving function, ankle range of motion, and spasticity at any time point (moderate- and low-quality evidence).BoNT-A is not associated with a higher risk of adverse events than serial casting (RR 0.59, 95% CI 0.03 to 11.03; 3 studies, 64 children; low-quality evidence).BoNT-A versus orthosesThere was no difference between groups for function at medium-term follow-up (MD 11.14, 95% CI -0.05 to 22.33; 1 study, 43 children), but BoNT-A is more effective than orthoses at improving hip range of motion and hip adductors spasticity (all very low-quality evidence). AUTHORS' CONCLUSIONS The quality of the evidence was low or very low for most of the outcomes analysed. We found limited evidence that BoNT-A is more effective than placebo or a non-placebo control at improving gait, joint range of motion, satisfaction, and lower limb spasticity in children with CP, whereas the results for function were contradictory. The rate of adverse events with BoNT-A is similar to placebo. BoNT-A is not more effective than ankle serial casting to treat ankle contractures for any of the assessed outcomes, but is more effective than orthotics at improving range of motion and spasticity.
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Affiliation(s)
- Francesco C Blumetti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5º andarSão PauloSão PauloBrazil04038‐032
| | - João Carlos Belloti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5º andarSão PauloSão PauloBrazil04038‐032
| | - Marcel JS Tamaoki
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5º andarSão PauloSão PauloBrazil04038‐032
| | - José A Pinto
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5º andarSão PauloSão PauloBrazil04038‐032
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Valentine J, Davidson SA, Bear N, Blair E, Ward R, Thornton A, Stannage K, Watson L, Forbes D, Elliott C. Botulinum toxin and surgical intervention in children and adolescents with cerebral palsy: who, when and why do we treat? Disabil Rehabil 2019; 43:936-943. [PMID: 31415723 DOI: 10.1080/09638288.2019.1644381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This audit aimed to increase understanding of the long-term outcomes of evidence-based medical and surgical interventions to improve gross motor function in children and adolescents with Cerebral Palsy. METHODS Retrospective audit of a birth cohort (2000-2009) attending a tertiary service in Western Australia. RESULTS The cohort comprises 771 patients aged 8 to 17 years. Percentage of children receiving no Botulinum Toxin treatments in each Gross Motor Functional Classification System level was: I: 40%, II: 26%, III: 33%, IV: 28% and V: 46%. Of the total cohort, 53% of children received 4 or less Botulinum Toxin treatments and 3.7% received more than 20 treatments. Statistically significant difference in the rate of use of Botulinum Toxin pre and post-surgery (p < 0.001) was documented. Children levels IV and V had 5 times the odds of surgery compared to children levels I-III (Odds Ratio 5.2, 95% Confidence Interval 3.5 to 7.8, p < 0.001). For 578 (75%) of participants the last recorded level was the same as the first. CONCLUSION This audit documents medical intervention by age and Gross Motor Functional Classification System level in a large cohort of children with cerebral palsy over time and confirms stability of the level in the majority.IMPLICATIONS FOR REHABILITATIONThe information from this audit may be of use in discussions with families regarding the timing and use of Botulinum toxin and surgical intervention for motor function in children and adolescents with Cerebral Palsy.Long term use of Botulinum Toxin within an integrated evidence-based clinical program is not associated with loss of gross motor function in the long term as evidenced by the maintenance of Gross Motor Functional Classification System stability.
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Affiliation(s)
- Jane Valentine
- School of Medicine University of Western Australia, Perth, Australia
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Perth, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Perth, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Ashleigh Thornton
- School of Medicine University of Western Australia, Perth, Australia
| | - Katherine Stannage
- Department of Orthopaedic Surgery, Perth Children's Hospital, Perth, Australia
| | - Linda Watson
- WA Register of Developmental Anomalies, King Edward Memorial Hospital, Subiaco, Australia
| | | | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
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Multani I, Manji J, Tang MJ, Herzog W, Howard JJ, Graham HK. Sarcopenia, Cerebral Palsy, and Botulinum Toxin Type A. JBJS Rev 2019; 7:e4. [DOI: 10.2106/jbjs.rvw.18.00153] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Pulgar S, Bains S, Gooch J, Chambers H, Noritz GH, Wright E, Sawhney TG, Pyenson B, Ferro C. Prevalence, Patterns, and Cost of Care for Children with Cerebral Palsy Enrolled in Medicaid Managed Care. J Manag Care Spec Pharm 2019; 25:817-822. [PMID: 31232210 PMCID: PMC10398069 DOI: 10.18553/jmcp.2019.25.7.817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In the United States, many children with cerebral palsy (CP) obtain health care coverage through managed Medicaid, but little is known about the current demographics or management of this high-need, complex population. OBJECTIVE To develop U.S. population-level information about the prevalence of CP, management patterns, and costs. METHODS Data (2013-2015) were analyzed from a managed Medicaid database with coverage of children and adolescents in 15 states. Analyses included demographic information and use of 10 prespecified CP management options often used to manage spasticity. Code-based algorithms were applied to indicate presence of spasticity and determine the likely ambulatory status. RESULTS In this claims analysis, the prevalence estimate of CP was 1.78 per 1,000 patients. Most (69.8%) children with CP had spasticity, of which 20.8% had hemiplegia, 15.6% diplegia, 32.9% quadriplegia, and 30.5% CP unspecified. Overall, 42.4% of children with CP were not treated with any of the 10 CP management options via Medicaid. Among treated children, the most common management options were physical therapy (37.1%), orthotics (29.9%), oral baclofen (13.5%) and botulinum toxins (9.4%). Overall annualized Medicaid costs were higher for children with CP versus children in the overall database population ($22,383 vs. $1,358). Within the CP population, costs were higher for those children who were likely nonambulatory than for those who were likely ambulatory ($43,687 vs. $10,368, respectively). CONCLUSIONS Most children with CP have spasticity, and the costs of care are high. This study highlights wide variation in the way CP is managed, with many young patients not receiving CP management options via Medicaid. DISCLOSURES This analysis was funded by Ipsen Biopharmaceuticals and conducted by Milliman. Pulgar and Bains were employees of Ipsen Biopharmaceuticals during the conduct of this study. Chambers is a consultant for OrthoPediatrics and an employee of the University of California. Pyenson and Ferro are employees of Milliman, as was Sawhney during the analysis. Gooch, Noritz, and Wright report no conflicts of interest. Part of this work was presented as a poster at TOXINS 2017: Basic Science and Clinical Aspects of Botulinum and Other Neurotoxins, held January 18-21, 2017, in Madrid, Spain.
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Affiliation(s)
- Sonia Pulgar
- Ipsen Biopharmaceuticals, Basking Ridge, New Jersey
| | | | | | - Henry Chambers
- Rady Children’s Hospital-San Diego, San Diego, California
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Guyot P, Kalyvas C, Mamane C, Danchenko N. Botulinum Toxins Type A (Bont-A) in the Management of Lower Limb Spasticity in Children: A Systematic Literature Review and Bayesian Network Meta-analysis. J Child Neurol 2019; 34:371-381. [PMID: 30803305 PMCID: PMC6512063 DOI: 10.1177/0883073819830579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/12/2018] [Accepted: 01/13/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Botulinum neurotoxins type A (BoNT-As) are used in pediatric lower limb spasticity, which affects more than 2.5 million children worldwide. Botulinum neurotoxins type-A improve active function and delay musculoskeletal complications. The objective of this analysis was to evaluate the efficacy and safety of abobotulinumtoxinA versus other botulinum neurotoxins type A in pediatric spasticity, in the absence of head-to-head evidence. METHODS A systematic literature review was conducted to identify relevant randomized controlled trials. The evidence base was synthesized with Bayesian network meta-analyses. Outcomes analyzed included Modified Ashworth Scale, Tardieu Scale (TS) spasticity grade, and Goal Attainment Scale (standard mean difference only) at 12 weeks postinjection, and adverse events occurring during study periods. RESULTS Thirty-eight studies were identified, 10 of which met inclusion criteria for quantitative synthesis. On Modified Ashworth Scale, abobotulinumtoxinA 15 U/kg/leg was significantly more efficacious than onabotulinumtoxinA 4 U/kg/leg (-0.99 [-1.34, -0.64]) and onabotulinumtoxinA 4 U/kg/leg+casting (-0.81 [-1.16, -0.46]) and numerically better than onabotulinumtoxinA 8 U/kg (-0.40 [-0.67, -0.14]). AbobotulinumtoxinA 10 U/kg/leg was significantly more efficacious than onabotulinumtoxinA 4 U/kg/leg (±casting). On Goal Attainment Scale, abobotulinumtoxinA 15 U/kg/leg and 10 U/kg/leg were significantly more efficacious than onabotulinumtoxinA 12 U/kg/leg. On Tardieu Scale spasticity grade, abobotulinumtoxinA was comparable to other treatments. AbobotulinumtoxinA demonstrated adverse event rates comparable to all doses of onabotulinumtoxinA. CONCLUSIONS In pediatric lower limb spasticity, abobotulinumtoxinA offered significant or numerical efficacy advantages on tone (Modified Ashworth Scale) and functional outcomes (Goal Attainment Scale), and comparable efficacy on Tardieu Scale spasticity grade. AbobotulinumtoxinA was comparable to onabotulinumtoxinA on tolerability. Results should be interpreted in the context of heterogeneity and sparsity of the evidence base.
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Horsch A, Götze M, Geisbüsch A, Beckmann N, Tsitlakidis S, Berrsche G, Klotz M. Prevalence and classification of equinus foot in bilateral spastic cerebral palsy. World J Pediatr 2019; 15:276-280. [PMID: 30830663 DOI: 10.1007/s12519-019-00238-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Equinus is a common deformity in children with bilateral spastic cerebral palsy (BSCP). While dynamic equinus usually is treated by conservative therapy, fixed contractures need surgical correction. To choose the appropriate surgical method, it is important to discriminate between isolated gastrocnemius shortening and combined gastrosoleus complex contracture. METHODS In a retrospective study 938 patients with BSCP were studied. Patients underwent gait analysis and clinical examination. 248 patients (496 limbs) met the inclusion criteria. Data from motion analysis and clinical examination were used to calculate the prevalence and to further classify fixed equinus foot. RESULTS The prevalence of equinus was 83.3%. During clinical exam 246 (59.6%) limbs showed combined gastrosoleus complex contracture and 167 (40.4%) isolated gastrocnemius contracture. Max. DF at stance and mean DF at initial contact were significantly reduced in combined contracture, while max. ROM was increased (P < 0.05). CONCLUSIONS Corroborating the results of previous studies, in this study there was a high prevalence of fixed equinus in patients with BSCP. The prevalence of equinus correlated with increasing age. As half of the patients with fixed equinus show a different involvement of gastrocnemius and soleus muscle, we recommend to apply Silfverskiöld's test to discriminate between those two types to choose the appropriate surgical therapy.
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Affiliation(s)
- Axel Horsch
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Marco Götze
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Andreas Geisbüsch
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Nicholas Beckmann
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Stefanos Tsitlakidis
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Gregor Berrsche
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Matthias Klotz
- Heidelberg University Hospital, Clinic for Orthopedics and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
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Kovalenko AP, Kamaeva OV, Misikov VK, Poleshchuk YR, Koshkarev MA. [Scales and tests in the rehabilitation and treatment of patients with spasticity of the lower limbs]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:120-128. [PMID: 29927416 DOI: 10.17116/jnevro201811851120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The problem-oriented approach in the rehabilitation of patients with spasticity requires careful assessment of the situation in the concept of The International Classification of Functioning, Disability and Health (ICF): impairment of the structure, functions and limitation of activity in specific environmental factors. Standardized tools in the assessment of muscle tone allow to get objective data about motor function. The use of the Modified Ashworth scale (MAS) and the Tardieu Scale are discussed. The standardized assessment of independent mobility is an important issue in outcome measuring. The ultimate goal of intervention, including the use of botulinum toxin therapy in the case of spasticity, is to support patient's daily activities. The article presents scales and tests for assessment of mobility: The Hauser Test, the Rivermead Mobility Index and functional assessment walking tests. The authors describe a clinical case of lower limb spasticity treatment with abobotulinumtoxin A and its assessment with these scales.
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Affiliation(s)
- A P Kovalenko
- Medical-military academy n.a. S.M. Kirov, Saint-Petersburg, Russia
| | - O V Kamaeva
- First St. Petersburg State Medical University n.a. academician I.P. Pavlov, Saint-Petersburg, Russia
| | - V K Misikov
- Moscow regional research clinical Institute. M.F. Vladimirsky, Moscow, Russia
| | - Yu R Poleshchuk
- Medical-military academy n.a. S.M. Kirov, Saint-Petersburg, Russia
| | - M A Koshkarev
- Medical-military academy n.a. S.M. Kirov, Saint-Petersburg, Russia
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Iskra DA, Kovalenko AP, Koshkarev MA, Frunza DN. [Combination of central and peripheral muscle relaxants in the treatment of post-stroke spasticity]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:51-57. [PMID: 32207718 DOI: 10.17116/jnevro201911912251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To study the electromiographic (EMG) parameters and to evaluate the therapeutic efficacy of a combination of central (baclofen, baclosan) and peripheral (incobotulotoxinA, xeomin) muscle relaxants in the treatment of post-stroke spasticity (PSS). MATERIAL AND METHODS Ninety-six patients with PSS of upper and lower limbs were divided into 2 groups: the first group (n=56) was treated with xeomin and the second (n=40) received combined therapy of xeomin and baclofen. Xeomin was administered according to the pattern of spasticity. The total dosage reached 800 U. Baclofen was used orally in a dose of 10 mg 3 times a day. The scales of paresis and spasticity assessment (MRCS, MAS and Tardieu), activity and participation of patients in everyday life (Bartel, Rankin, Rivermead mobility Index, comfortable walking test, LASIS) were used. EMG and transcranial magnetic stimulation (TMS) were performed. M-response, H-reflex, F-wave, central conduction time were determined. The total duration of the study was 120 days. Patients were assessed at 4 points. RESULTS AND CONCLUSION Potentiation of peripheral and central muscle relaxants and prolongation of the effect of xeomin was revealed (it was expressed in the reduction of the number of injection sessions from 7-8 to 5-6). The use of xeomin in a total dosage of up to 800 U has shown its efficacy and safety for the treatment of spasticity of the upper and lower limbs. The results of EMG and TMS shed a light on the mechanisms of the therapeutic effect of combined (xeomin+baclosan) and monotherapy (xeomin) spasticity.
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Affiliation(s)
- D A Iskra
- Kirov Medical-Military Academy, St-Petersburg, Russia
| | - A P Kovalenko
- Kirov Medical-Military Academy, St-Petersburg, Russia
| | - M A Koshkarev
- Branch N 5 Vishnevsky 3th Central Military Clinical Hospital, Sergiev Posad, Russia
| | - D N Frunza
- Kirov Medical-Military Academy, St-Petersburg, Russia
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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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AbobotulinumtoxinA (Dysport ®), OnabotulinumtoxinA (Botox ®), and IncobotulinumtoxinA (Xeomin ®) Neurotoxin Content and Potential Implications for Duration of Response in Patients. Toxins (Basel) 2018; 10:toxins10120535. [PMID: 30551641 PMCID: PMC6316182 DOI: 10.3390/toxins10120535] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/05/2018] [Accepted: 12/11/2018] [Indexed: 01/12/2023] Open
Abstract
Botulinum neurotoxin type-A (BoNT-A) blocks the release of acetylcholine from peripheral cholinergic nerve terminals and is an important option for the treatment of disorders characterised by excessive cholinergic neuronal activity. Several BoNT-A products are currently marketed, each with unique manufacturing processes, excipients, formulation, and non-interchangeable potency units. Nevertheless, the effects of all the products are mediated by the 150 kDa BoNT-A neurotoxin. We assessed the quantity and light chain (LC) activity of BoNT-A in three commercial BoNT-A products (Dysport®; Botox®; Xeomin®). We quantified 150 kDa BoNT-A by sandwich ELISA and assessed LC activity by EndoPep assay. In both assays, we assessed the results for the commercial products against recombinant 150 kDa BoNT-A. The mean 150 kDa BoNT-A content per vial measured by ELISA was 2.69 ng/500 U vial Dysport®, 0.90 ng/100 U vial Botox®, and 0.40 ng/100 U vial Xeomin®. To present clinically relevant results, we calculated the 150 kDa BoNT-A/US Food and Drug Administration (FDA)-approved dose in adult upper limb spasticity: 5.38 ng Dysport® (1000 U; 2 × 500 U vials), 3.60 ng Botox® (400 U; 4 × 100 U vials), and 1.61 ng Xeomin® (400 U; 4 × 100 U vials). EndoPep assay showed similar LC activity among BoNT-A products. Thus, greater amounts of active neurotoxin are injected with Dysport®, at FDA-approved doses, than with other products. This fact might explain the long duration of action reported across multiple indications, which benefits patients, caregivers, clinicians, and healthcare systems.
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Abstract
BACKGROUND The evidence-based approach to guide clinical practice has gained great importance in the medical field. High-quality evidence is of paramount importance to inform clinical decision-making and optimize patient outcomes. The generation of high-quality evidence relies on sound methodology and study design to facilitate appropriate interpretation and subsequent application of the clinical findings. The purpose of this review is to objectively critique the methodological design and clinical findings of 2 pediatric orthopaedic studies on children with cerebral palsy (CP) to assess their potential to impact clinical practice. METHODS This is the second in a series of evidence-based reviews in pediatric orthopaedics. The pediatric orthopaedic literature was reviewed for randomized controlled trials (RCTs) published in 2015 and 2016. One RCT was selected from the journal Pediatrics, and one RCT was selected from the journal Developmental Medicine and Child Neurology, both investigating the use of botulinum toxin for the treatment of spastic equinus in children with CP. These RCTs were subjected to in-depth methodological review by orthopaedic surgeons with advanced research degrees and a PhD researcher. Two clinical experts then reviewed the articles to rate the clinical impact or value of each study. Methodological and clinical reviews were compiled, and a final recommendation on impact to change clinical practice was made based on both review components at the consensus of the panel. RESULTS The first study reviewed investigated the single-dose efficacy and safety of botulinum neurotoxin type-A (1BoNT-A) in children with CP-associated spasticity and equinus foot deformity. The reviewers deemed the placebo-controlled study to be of sound design, and conclusions appropriate for the methodology used and clinical findings. Although findings suggest 1BoNT-A may provide benefit in treating equinus foot deformity, the optimal dose for achieving maximal impact on functional improvement remains undetermined. The second study reviewed investigated the impact of multiple dosing schedules on spastic equinus in CP. Although of relatively sound design, this study was limited by a small sample size and lack of justification for the chosen effect size. Without further study, no recommendation to change clinical practice could be made. CONCLUSIONS Both RCTs reviewed were superiority studies, the first demonstrating efficacy of botulinum toxin over placebo, the second showing no significant difference in 4- and 12-monthly botulinum toxin injections. SIGNIFICANCE Despite a positive result demonstrating an effect of botulinum toxin treatment on spastic equinus in CP, the long-term functional impact and optimal dose remains to be determined. In addition, the negative result in the second study demonstrates the need for a noninferiority trial design to appropriately demonstrate no difference between 2 treatment options.
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Hastings-Ison T, Sangeux M, Thomason P, Rawicki B, Fahey M, Graham HK. Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: a prospective kinematic study. J Child Orthop 2018; 12:390-397. [PMID: 30154931 PMCID: PMC6090192 DOI: 10.1302/1863-2548.12.180044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Botulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis. METHODS This was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance. RESULTS In all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58. CONCLUSION Injections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee. LEVEL OF EVIDENCE II - prospective cohort study, before and after intervention.
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Affiliation(s)
- T. Hastings-Ison
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, Victoria, Australia,Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, Parkville, Victoria, Australia, Correspondence should be sent to T. Hastings-Ison, Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia. E-mail:
| | - M. Sangeux
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, Victoria, Australia,Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, Parkville, Victoria, Australia,Melbourne School of Engineering, University of Melbourne, Parkville, Victoria, Australia
| | - P. Thomason
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, Victoria, Australia,Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, Parkville, Victoria, Australia
| | - B. Rawicki
- Victorian Paediatric Rehabilitation Service, Monash Children’s Hospital, Clayton, Victoria, Australia,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - M Fahey
- Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - H. K. Graham
- Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, Parkville, Victoria, Australia,National Health and Medical Research Council, Centre of Research Excellence in Cerebral Palsy, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Erbil D, Tugba G, Murat TH, Melike A, Merve A, Cagla K, Mehmetali ÇC, Akay Ö, Nigar D. Effects of robot-assisted gait training in chronic stroke patients treated by botulinum toxin-a: A pivotal study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018; 23:e1718. [DOI: 10.1002/pri.1718] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/13/2018] [Accepted: 04/14/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Dursun Erbil
- Department of Physical Medicine and Rehabilitation; Kocaeli University; Kocaeli Turkey
| | | | - Topcu Hasan Murat
- BAMA Technology Medical Devices Consultancy and Health Information Technology Industry and Trade Limited Company; ODTU Technocity; Ankara Turkey
| | - Akarsu Melike
- Resident of the Department of Physical Therapy and Rehabilitation, Izmit Rehabilitation and Training Center; Kocaeli University Medical School; Kocaeli Turkey
| | - Akyüz Merve
- Resident of the Department of Physical Therapy and Rehabilitation, Izmit Rehabilitation and Training Center; Kocaeli University Medical School; Kocaeli Turkey
| | - Karacan Cagla
- Resident of the Department of Physical Therapy and Rehabilitation, Izmit Rehabilitation and Training Center; Kocaeli University Medical School; Kocaeli Turkey
| | - Çiftçi Can Mehmetali
- BAMA Technology Medical Devices Consultancy and Health Information Technology Industry and Trade Limited Company; ODTU Technocity; Ankara Turkey
| | - Öztürk Akay
- BAMA Technology Medical Devices Consultancy and Health Information Technology Industry and Trade Limited Company; ODTU Technocity; Ankara Turkey
| | - Dursun Nigar
- Department of Physical Medicine and Rehabilitation; Kocaeli University; Kocaeli Turkey
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Dabrowski E, Bonikowski M, Gormley M, Volteau M, Picaut P, Delgado MR. AbobotulinumtoxinA Efficacy and Safety in Children With Equinus Foot Previously Treated With Botulinum Toxin. Pediatr Neurol 2018; 82:44-49. [PMID: 29625849 DOI: 10.1016/j.pediatrneurol.2017.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/30/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of botulinum toxin are transient, and repeat injections are required in children with lower-limb spasticity. However, the efficacy of botulinum toxin in patients who have received previous injections has remained largely unexplored. METHODS We present subgroup analyses of a phase III study conducted in ambulatory children (aged two to 17) with spastic equinus foot. Patients were randomized to single doses of abobotulinumtoxinA 10 U/kg/leg, 15 U/kg/leg, or placebo injected into the gastrocnemius-soleus complex (one or both legs). The first analysis was prespecified to review the effect of abobotulinumtoxinA in children previously treated with botulinum toxin versus those children new to the treatment; a second post hoc analysis evaluated the effect of abobotulinumtoxinA in children who changed botulinum toxin formulation. RESULTS Of the 241 randomized patients, 113 had previously received botulinum toxin, including 86 who had been treated with another formulation. In both analyses, muscle tone (Modified Ashworth Scale) and the Physicians Global Assessment, at week 4, improved with abobotulinumtoxinA treatment versus placebo, regardless of baseline botulinum toxin status. Placebo responses in patients new to treatment were consistently higher than in the previously treated group. CONCLUSIONS These results demonstrate similar abobotulinumtoxinA efficacy and safety profiles in children with spasticity who are new to botulinum toxin treatment and those children who were previously treated. The efficacy and safety of abobotulinumtoxinA treatment in these previously treated patients were comparable with the overall trial population, indicating that doses of 10 and 15 U/kg/leg are suitable starting doses for children with spasticity regardless of the previous botulinum toxin preparation used.
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Affiliation(s)
- Edward Dabrowski
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, Michigan.
| | | | - Mark Gormley
- Gillette Children's Specialty Healthcare, St Paul, Minnesota
| | | | | | - Mauricio R Delgado
- Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas, Texas
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Botulinum-A intramuscular injection in an orthopaedic paediatric patient cohort: service restructure analysis. J Pediatr Orthop B 2018; 27:189-193. [PMID: 28704302 DOI: 10.1097/bpb.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Botulinum intramuscular injections are increasingly being used in the management of hypertonic musculature. Historically, injections were administered under general anaesthesia (GA), which has service and economic implications. Our delivery changed to outpatient conscious injections to improve service efficiency. A retrospective analysis of all patient injections from January 2010 to December 2015 analysed cost-benefit and efficiency of service remodelling. 472 patients were administered injections, 298 in theatre under GA and 174 without GA. In 2010, 97 of 102 cases were performed under GA (45 theatre-hours), decreasing to 18 of 68 cases in 2015 (8.4 theatre-hours). The mean hospital stay decreased from 410 to 135 min. The reduction in theatre use and the requirement for a postanaesthetic bed led to significant savings per case. Service remodelling showed successful cost saving and reduced in-hospital stay.
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Delgado MR, Bonikowski M, Carranza J, Dabrowski E, Matthews D, Russman B, Tilton A, Velez JC, Grandoulier AS, Picaut P. Safety and Efficacy of Repeat Open-Label AbobotulinumtoxinA Treatment in Pediatric Cerebral Palsy. J Child Neurol 2017; 32:1058-1064. [PMID: 28914131 PMCID: PMC5652649 DOI: 10.1177/0883073817729918] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This was a prospective, repeat-treatment, open-label study (NCT01251380) of abobotulinumtoxinA for the management of lower limb spasticity in children who had completed a double-blind study. Children (2-17 years) received injections into the gastrocnemius-soleus complex, and other distal and proximal muscles as required (maximum total dose per injection cycle: 30 U/kg or 1000U). A total of 216 of the 241 double-blind patients entered the extension study and 207 received ≥1 open label injection into the gastrocnemius-soleus; 17-24% of patients also had injections into the hamstrings. The most frequent adverse events were related to common childhood infections and the most frequent treatment-related adverse event was injection site pain (n = 10). There was no evidence of a cumulative effect on adverse events. Sustained significant clinical improvements in muscle tone (Modified Ashworth Scale), spasticity (Tardieu Scale), overall clinical benefit (Physicians Global Assessment), and goal attainment (Goal Attainment Scale) were also observed across treatment cycles.
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Affiliation(s)
- Mauricio R Delgado
- 1 University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | | | | | - Edward Dabrowski
- 4 Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI, USA
| | | | - Barry Russman
- 6 Shriner's Hospital for Children, Portland, OR, USA
| | - Ann Tilton
- 7 LSUHSC and Children's Hospital New Orleans, New Orleans, LA, USA
| | - Juan Carlos Velez
- 8 Centro de Rehabilitacion Club De Leones Cruz del Sur, Punta Arenas, Chile
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Chang HJ, Hong BY, Lee SJ, Lee S, Park JH, Kwon JY. Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Dynamic Equinus Foot Deformity in Children with Cerebral Palsy: A Randomized Controlled Trial. Toxins (Basel) 2017; 9:toxins9080252. [PMID: 28820439 PMCID: PMC5577586 DOI: 10.3390/toxins9080252] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022] Open
Abstract
The objective of this clinical trial was to compare the efficacy and safety of letibotulinum toxin A and onabotulinum toxin A for improving dynamic equinus foot deformity in children with cerebral palsy (CP). In total, 144 children with spastic CP who had dynamic equinus foot deformity were assigned randomly to the Botulax group (injection of letibotulinum toxin A) or the Botox group (injection of onabotulinum toxin A). The Physician’s Rating Scale (PRS), ankle plantar flexor spasticity using the Modified Tardieu Scale, the Gross Motor Function Measure (GMFM)-88, and the GMFM-66 were completed before injection and at 6, 12, and 24 weeks after injection. The PRS responder rate was 60.27% in the Botulax group and 61.43% in the Botox group at 12 weeks after treatment, and the lower limit of the 95% confidence interval for the between-group difference in responder rates was −17.16%, higher than the non-inferiority margin of −24.00%. The clinical efficacy and the safety profiles of the groups did not significantly differ. The results suggest that injection of letibotulinum toxin A is as effective and safe as that of onabotulinum toxin A for the treatment of dynamic equinus foot deformity in children with spastic CP.
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Affiliation(s)
- Hyun Jung Chang
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, South Korea.
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, South Korea.
| | - Sang-Jee Lee
- Department of Rehabilitation Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, South Korea.
| | - Soyoung Lee
- Department of Rehabilitation Medicine, Keimyung University, Dongsan Medical Center, Daegu 41931, South Korea.
| | - Joo Hyun Park
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea.
| | - Jeong-Yi Kwon
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea.
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Cocco A, Albanese A. Recent developments in clinical trials of botulinum neurotoxins. Toxicon 2017; 147:77-83. [PMID: 28818530 DOI: 10.1016/j.toxicon.2017.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/10/2017] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxins (BoNTs) are increasingly used in clinical practice for several indications. Following the pioneering years of discoveries, the recent years have witnessed an increase of new indications and new toxin brands. We review here the clinical trials on BoNTs performed since 2014 and put them into perspective. We also review the ongoing trials listed by the National Institutes of Health registry (Clinicaltrials.gov). The following indications are reviewed here: blepharospasm, cervical dystonia, spasticity, cerebral palsy, urinary incontinence, headache, topical formulations, postoperative cardiac arrhythmia, keloids and scars. For each of these indications the latest trials are reviewed and commented.
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Affiliation(s)
| | - Alberto Albanese
- Humanitas Research Hospital, Rozzano, Milano, Italy; Catholic University, Milano, Italy.
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Abstract
AbobotulinumtoxinA (Dysport®) is currently the only botulinum toxin A formulation approved by the US FDA for the treatment of lower limb spasticity in pediatric patients aged ≥2 years. Intramuscular abobotulinumtoxinA was approved based on the results of a pivotal phase 3 trial in children with lower limb spasticity due to cerebral palsy. In this trial, a single treatment cycle with abobotulinumtoxinA 10-15 U/kg/leg injected into the gastrocnemius and soleus muscles significantly improved ankle plantar flexor muscle tone (primary endpoint), with abobotulinumtoxinA recipients showing a significant response to treatment relative to placebo. AbobotulinumtoxinA treatment also improved spasticity grade. The improvements in muscle tone and spasticity were associated with an improved ability to attain functional goals. Clinical benefits of abobotulinumtoxinA treatment lasted for 16-22 weeks in most patients, and were maintained with multiple treatment cycles during 1 year in an open-label extension study. AbobotulinumtoxinA was generally well tolerated, with a relatively low incidence of treatment-related adverse events. In summary, abobotulinumtoxinA is an effective and generally well tolerated treatment option for children with lower limb spasticity.
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Tilton A, Russman B, Aydin R, Dincer U, Escobar RG, Kutlay S, Lipczyk Z, Velez JC, Grandoulier AS, Tse A, Picaut P, Delgado MR. AbobotulinumtoxinA (Dysport ®) Improves Function According to Goal Attainment in Children With Dynamic Equinus Due to Cerebral Palsy. J Child Neurol 2017; 32:482-487. [PMID: 28068857 PMCID: PMC5405835 DOI: 10.1177/0883073816686910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This secondary analysis of a large (n = 241), randomized, double-blind study evaluated the efficacy of 2 doses of abobotulinumtoxinA + standard of care (SOC) versus placebo + SOC in enabling children with dynamic equinus due to cerebral palsy to achieve their functional goals using Goal Attainment Scaling. Most parents/caregivers selected goals targeting aspects of gait improvement as most relevant. Mean (95% confidence interval) Goal Attainment Scaling T scores at week 4 were higher for both abobotulinumtoxinA groups versus placebo (treatment difference vs placebo: 10 U/kg/leg: 5.32 [2.31, 8.32], P = .0006, and 15 U/kg/leg 4.65 [1.59, 7.71], P = .0031). Superiority of both abobotulinumtoxinA doses versus placebo was maintained at week 12. Best goal attainment T scores were higher in the abobotulinumtoxinA groups versus placebo for the common goals of improved walking pattern, decreased falling, decreased tripping, and improved endurance. These findings demonstrate that single injections of abobotulinumtoxinA (10 and 15 U/kg/leg) significantly improved the ability of pediatric cerebral palsy patients to achieve their functional goals.
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Affiliation(s)
- Ann Tilton
- 1 LSUHSC and Children's Hospital New Orleans, New Orleans, LA, USA
| | - Barry Russman
- 2 Shriner's Hospital for Children, Portland, OR, USA
| | | | - Umit Dincer
- 4 GATA Haydarpasa Training Hospital, Istanbul, Turkey
| | - Raul G Escobar
- 5 Unit of Neurology, Division of Pediatrics, Medical School, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Sehim Kutlay
- 6 Department of PMR, Ankara University, Faculty of Medicine, Ankara, Turkey
| | | | - Juan Carlos Velez
- 8 Club De Leones Cruz Del Sur Rehabilitation Center, Punta Arenas, Chile
| | | | | | | | - Mauricio R Delgado
- 10 University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas, TX, USA
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Kurenkov AL, Klochkova OA, Zmanovskaya VA, Falkovskiy IV, Kenis VM, Vladykina LN, Krasavina DA, Nosko AS, Rychkova LV, Karimova KM, Bursagova BI, Namazova-baranova LS, Mamedyarov AM, Kuzenkova LM, Dontzov OG, Ryzhenkov MA, Butorina MN, Pavlova OL, Harlamova NN, Dankov DM, Levitina EV, Popkov DA, Ryabykh SO, Medvedeva SN, Gubina EB, Agranovich OV, Kiseleva TI, Vasileva ON, Zykov VP, Mihnovich VI, Belogorova ТА. The First Russian Consensus on the Multilevel Abobotulinumtoxin A Injections in Spastic Forms of Cerebral Palsy. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:121-130. [DOI: 10.17116/jnevro2016116111121-130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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